Nokea
A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy?
- A. A patient 35 years old
- B. A patient 68 years old
- C. A patient with a college degree
- D. A patient with a high-school diploma
Correct Answer: D
Rationale: The correct answer is D because patients with lower health literacy, such as those with a high-school diploma, may struggle to understand complex health information. The nurse should assess this patient closely to ensure they comprehend and can follow instructions. Patients with higher education levels (college degree) may have better health literacy skills. Age alone (35 or 68 years old) does not determine health literacy level. It is essential to focus on the patient's educational background to assess their health literacy effectively.
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A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
- A. The nurse wears face protection, gloves, and a gown when irrigating a wound.
- B. The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves.
- C. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
- D. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.
Correct Answer: C
Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale:
1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination.
2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens.
3. This behavior shows a lack of understanding of proper infection control practices.
Summary of other choices:
A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice.
B: Washing hands with waterless antiseptic after removing soiled gloves is correct.
D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.
A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patients subsequent care, the nurse should prioritize actions with what goal?
- A. Preventing hemorrhage
- B. Ensuring the patient knows the treatment is palliative, not curative
- C. Protecting the safety of the patient, family, and staff
- D. Ensuring that the patient adheres to dietary restrictions during treatment
Correct Answer: C
Rationale: The correct answer is C: Protecting the safety of the patient, family, and staff. This is the priority when planning care for a patient undergoing radiation therapy due to the potential risks of radiation exposure to others. Ensuring safety involves implementing proper radiation safety protocols, educating the patient and family on safety measures, and providing a safe environment for all.
Choices A, B, and D are incorrect. Preventing hemorrhage is important but not the top priority during radiation therapy. Ensuring the patient understands the treatment's purpose is essential but not the immediate priority. Adherence to dietary restrictions is important for overall health but is not the primary focus when prioritizing actions for radiation therapy.
The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hypercapnia
- D. Hypocapnia
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin.
Incorrect choices:
B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case.
C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described.
D: Hypocapnia - This is low carbon dioxide levels
Rh incompatibility can occur if the patient is Rh-negative and the
- A. fetus is Rh-negative.
- B. fetus is Rh-positive.
- C. father is Rh-positive.
- D. father and fetus are both Rh-negative.
Correct Answer: B
Rationale: The correct answer is B because Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. If fetal blood enters the mother's circulation during pregnancy or childbirth, the mother's immune system can produce antibodies against Rh-positive red blood cells, leading to potential harm to future pregnancies. Choices A, C, and D are incorrect because Rh incompatibility does not occur when the fetus is Rh-negative, the father is Rh-positive, or both the father and fetus are Rh-negative.
A nurse knows of several patients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which patient?
- A. A patient who has previously been treated for tuberculosis
- B. A pregnant woman at 30 weeks gestation
- C. A patient who is on estrogen-replacement therapy
- D. A patient with a severe allergy to eggs
Correct Answer: B
Rationale: The correct answer is B. Antihistamines are generally considered safe during pregnancy, but it is recommended to avoid unnecessary medications, especially in the third trimester. Antihistamines should be used cautiously in pregnant women due to potential effects on the fetus. Choice A is incorrect because previous treatment for tuberculosis does not contraindicate the use of antihistamines. Choice C is incorrect as estrogen-replacement therapy does not interact significantly with antihistamines. Choice D is incorrect as a severe allergy to eggs does not directly contraindicate the use of antihistamines.