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A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patients skin appears yellow. Which blood tests should be done to further explore this clinical sign?
- A. Liver function tests (LFTs)
- B. Complete blood count (CBC)
- C. Platelet count
- D. Blood urea nitrogen and creatinine
Correct Answer: A
Rationale: The correct answer is A: Liver function tests (LFTs). Yellow skin can indicate jaundice, a sign of liver dysfunction, often seen in patients with liver issues or chemotherapy-related liver toxicity. LFTs including bilirubin, ALT, AST, and ALP can help assess liver function.
B: Complete blood count (CBC) and C: Platelet count are not directly related to yellow skin and would not provide information on liver function.
D: Blood urea nitrogen and creatinine are tests for kidney function, not liver function. While kidney dysfunction can sometimes cause yellow skin, LFTs are more specific for assessing liver function in this context.
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A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patients immediate postoperative recovery?
- A. Teaching the patient about options for eye prostheses
- B. Teaching the patient to estimate depth and distance with the use of one eye
- C. Assessing and addressing the patients emotional needs
- D. Teaching the patient about his post-discharge medication regimen
Correct Answer: C
Rationale: The correct answer is C: Assessing and addressing the patient's emotional needs. This should be prioritized because the patient has undergone a traumatic experience losing their eye due to a workplace accident. Emotions such as fear, anxiety, and grief are common postoperatively. Addressing these emotional needs is crucial for the patient's overall well-being and recovery. Options A, B, and D are important aspects of care but not the priority in this situation. Teaching about eye prostheses, depth perception, and medication regimen can be addressed once the patient's emotional needs are stabilized.
A patient with a genital herpes exacerbation has a nursing diagnosis of acute pain related to the genital lesions. What nursing intervention best addresses this diagnosis?
- A. Cover the lesions with a topical antibiotic.
- B. Keep the lesions clean and dry.
- C. Apply a topical NSAID to the lesions.
- D. Remain on bed rest until the lesions resolve.
Correct Answer: B
Rationale: The correct answer is B: Keep the lesions clean and dry. This intervention helps prevent infection and promotes healing. Cleaning the lesions reduces the risk of secondary infections and discomfort. Keeping the area dry can also help alleviate pain and discomfort associated with moisture. Covering with a topical antibiotic (A) may not address pain directly and could potentially irritate the lesions. Applying a topical NSAID (C) may provide some pain relief but does not address the primary need to keep the lesions clean and dry. Remaining on bed rest (D) is not necessary for managing acute pain related to genital lesions.
A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following?
- A. Static stage
- B. Latent stage
- C. Viral set point
- D. Window period
Correct Answer: C
Rationale: The correct answer is C: Viral set point. The viral set point refers to the stable level of HIV in the body after the initial infection. This state indicates a balance between viral replication and the immune response. The other choices are incorrect because: A) Static stage implies no change, which is not the case with HIV levels fluctuating; B) Latent stage refers to a period of inactivity, not the stable state described; D) Window period is the time between infection and detectable antibodies, not the equilibrium state described.
A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patients discharge education?
- A. Expected changes in facial nerve function
- B. The need for audiometry testing every 6 months following recovery
- C. Safe use of analgesics and antivertiginous agents
- D. Appropriate use of OTC ear drops
Correct Answer: C
Rationale: Step 1: After mastoid surgery, patients may experience pain and dizziness, hence addressing the safe use of analgesics and antivertiginous agents is crucial for symptom management.
Step 2: Analgesics help in managing post-operative pain, while antivertiginous agents help control dizziness, reducing the risk of falls.
Step 3: Educating the patient on safe use ensures proper pain and symptom management, preventing complications.
Step 4: Other choices are incorrect as they do not directly address immediate post-operative care needs such as pain and dizziness management.
A nurse is checking orders. Which order shouldthe nurse question?
- A. A normal saline enema to be repeated every 4 hours until stool is produced
- B. A hypertonic solution enema for a patient with fluid volume excess
- C. A Kayexalate enema for a patient with severe hypokalemia
- D. An oil retention enema for a patient with constipation
Correct Answer: B
Rationale: The correct answer is B because giving a hypertonic solution enema to a patient with fluid volume excess can worsen the condition by drawing more fluid into the colon. This can lead to further fluid volume overload and electrolyte imbalances. The other choices are incorrect because:
A: Normal saline enema is appropriate for constipation.
C: Kayexalate enema is used to treat hyperkalemia, not hypokalemia.
D: Oil retention enema is indicated for constipation to soften stool.