Nokea
Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?
- A. Bruising around the operative site
- B. Pain
- C. Irritability
- D. Fever
Correct Answer: D
Rationale: Patients who have undergone splenectomy are at risk for overwhelming postsplenectomy infection (OPSI) due to the absence of a functioning spleen, which is important in fighting certain types of infections, especially those caused by encapsulated bacteria such as Streptococcus pneumoniae. Symptoms of OPSI can include fever, chills, weakness, and rapid breathing. Fever is a significant sign that alerts the nurse to the possibility of OPSI in a post-splenectomy patient, as it may indicate an infection that the body is struggling to fight without the spleen's immune support. This is a crucial symptom to monitor and act upon promptly to prevent serious complications in these individuals.
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gauge needle for drawing up medication and injecting it
- A. Inject the medication in the upper arm muscle
- B. Use a 1 inch needle to administer the medication
- C. Use the Z track technique to administer the medication
Correct Answer: B
Rationale: Using a 1 inch needle is the appropriate gauge needle for drawing up medication and injecting it. The length of the needle is important to ensure that the medication reaches the intended target area and is administered effectively. Shorter needles may not penetrate deep enough, while longer needles may increase the risk of complications such as injecting the medication into the wrong tissue or causing discomfort to the patient. Therefore, using a 1 inch needle is the correct choice for administering medication safely and accurately.
A 90 y.o. nursing home resident with stage 2 Alzheimer's disease is found alone and crying in the dining room. She says she lost her mother and doesn't know what to do. Which response by the nurse will help calm the resident?
- A. "Remember your mother has been dead for 30 years. You forgot again, didn't you?"
- B. "I'm sorry you lost your mother; let's go and try to find her."
- C. "Are you feeling frightened? I'm here and I will help you."
- D. "You are 90 years old. It is impossible for your mother to still be living. I know if you try, you can figure out what to do."
Correct Answer: C
Rationale: Option C, "Are you feeling frightened? I'm here and I will help you," is the most appropriate response to help calm the resident. The resident is experiencing confusion and distress, likely due to her Alzheimer's disease. Invalidating her feelings by reminding her of the reality may lead to more confusion and distress. Instead, acknowledging the resident's emotions, offering support, and reassuring her of your presence can help calm her down and provide comfort in the moment. It is important to provide emotional support and reassurance to individuals with Alzheimer's disease, rather than focusing on correcting their statements or reminding them of reality.
For a 14-month-old whose cleft palate was repaired 12 hours ago, which should be included in the plan of care?
- A. Allow familiar comfort items (e.g., favorite stuffed animal) and a 'sippy' cup (avoid suction items).
- B. Once liquids are tolerated, encourage a bland diet (e.g., soup, Jell-O, saltine crackers).
- C. Administer scheduled pain medication rather than PRN only.
- D. Use a Yankauer suction catheter to decrease aspiration risk.
Correct Answer: A
Rationale: Providing comfort items and avoiding suction items helps reduce distress and supports healing.
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
- A. Protein
- B. Vitamin A
- C. Fat
- D. Zinc
Correct Answer: C
Rationale: Excessive ingestion of fat has been linked to autoimmunity. A diet high in saturated and trans fats can lead to chronic inflammation and disrupt the balance of immune cells, potentially triggering autoimmune responses in the body. Conversely, a nutritionally balanced diet that includes healthy fats like omega-3 fatty acids from sources such as fish, nuts, and seeds can help support optimal immunologic function and reduce the risk of autoimmune disorders.
A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.)
- A. Elicit one answer at a time.
- B. Interrupt the interpreter if the response from the family is lengthy.
- C. Comments to the interpreter about the family should be made in English.
- D. Arrange for the family to speak with the same interpreter, if possible.
Correct Answer: A
Rationale: Elicit one answer at a time: By eliciting one answer at a time, the nurse can ensure clarity in communication and prevent confusion or information overload for both the patient and interpreter.