Nokea
A patient has cloudy penile discharge. For which additional symptoms of urethritis should the nurse assess?
- A. Throat or rectal infection
- B. Chancres or vesicles on the genitals
- C. Painful and frequent urination
- D. Oliguria and flank pain
Correct Answer: C
Rationale: Cloudy penile discharge is a common symptom of urethritis, which is inflammation of the urethra usually caused by an infection, such as a sexually transmitted infection (STI) like gonorrhea or chlamydia. Painful and frequent urination are also classic symptoms of urethritis. Painful urination, or dysuria, may occur due to the irritation and inflammation of the urethra. Frequency of urination can be a result of the body's response to the infection or inflammation. Therefore, assessing for these additional symptoms helps in confirming the diagnosis of urethritis and determining the appropriate treatment for the patient.
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Which of the following nursing interventions will help prevent a further increase in ICP?
- A. Encourage fluids
- B. Provide physical therapy
- C. Elevate the head of the bed
- D. Reposition the patient frequently
Correct Answer: C
Rationale: Elevating the head of the bed helps to promote venous drainage from the brain, which can help reduce intracranial pressure (ICP). By positioning the patient with the head of the bed at a 30-45 degree angle, it can facilitate the circulation of cerebrospinal fluid and blood, thus preventing a further increase in ICP. This intervention is a crucial aspect of managing patients with increased ICP and can help improve their overall neurological status.
Which of the following guidekines does not observe surgical asepisi in the operating room?
- A. sterile articles may touch other sterile articles or surface and remain sterile
- B. gowns of surgical team are considered sterile in front from the chest down to the bottom of the gown
- C. whenever a sterile barrier is breached, the area must be considered contaminated
- D. sterile drapes are used to create a sterile field
Correct Answer: A
Rationale: This statement is incorrect and does not observe surgical asepsis in the operating room. In surgical asepsis, it is crucial that sterile articles do not touch other sterile articles or surfaces to prevent contamination. Any contact between sterile items or surfaces can lead to the transfer of microorganisms, compromising the sterility of the environment. Maintaining a sterile field is essential to prevent surgical site infections and ensure the safety of the patient undergoing the procedure.
A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drug falls into this category?
- A. Procainamide (Pronestyl)
- B. Phenytoin (Dilantin)
- C. Azathioprine (Imuran)
- D. Allopurinol (Zyloprim)
Correct Answer: B
Rationale: Gingival hyperplasia, or overgrowth of gum tissue, is a common side effect associated with certain medications, particularly anti-seizure medications like phenytoin (Dilantin). This side effect can be minimized through good oral hygiene practices, such as regular brushing and flossing of the teeth. The client must pay extra attention to oral care while taking phenytoin in order to prevent or reduce the severity of gingival hyperplasia. It is important for healthcare providers to educate clients on the importance of oral hygiene with medications associated with this side effect.
How many drops per minute should be delivered?
- A. 6
- B. 17
- C. 50
- D. 100
Correct Answer: B
Rationale: The standard drip factor for an IV infusion set is typically 15 drops per milliliter. To calculate drops per minute, you would multiply the flow rate in milliliters per hour by the drip factor and divide by 60 minutes per hour.
An infant has been diagnosed with cow's milk allergy. What are the clinical manifestations the nurse expects to assess? (Select all that apply.)
- A. Pink mucous membranes
- B. Vomiting
- C. Rhinitis
- D. Abdominal pain
Correct Answer: B
Rationale: Pink mucous membranes are not a typical clinical manifestation of cow's milk allergy. Allergies often present with symptoms affecting the gastrointestinal tract, respiratory system, skin, or a combination of these systems.