Nokea
A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene?
- A. Custard
- B. Frozen yogurt
- C. Pureed vegetables
- D. Mashed potatoes and gravy
Correct Answer: D
Rationale: Mashed potatoes and gravy are not appropriate for a full liquid diet. A full liquid diet consists of foods that are liquid at room temperature or melt into liquid form at body temperature. Mashed potatoes and gravy are not in liquid form and therefore should not be consumed by a patient following a full liquid diet. The nurse should intervene and provide education about the correct food choices allowed on a full liquid diet, such as custard, frozen yogurt, and pureed vegetables.
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The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?
- A. Run lipids for no longer than 24 hours.
- B. Take down a running bag of TPN after 36 hours.
- C. Clean injection port with alcohol 5 seconds before and after use.
- D. Wear a sterile mask when changing the central venous catheter dressing.
Correct Answer: D
Rationale: When caring for a patient receiving total parenteral nutrition (TPN), it is crucial to maintain strict aseptic technique to prevent infection. Wearing a sterile mask when changing the central venous catheter dressing helps to reduce the risk of introducing pathogens into the catheter site, which can lead to serious bloodstream infections. It is essential to use sterile gloves, a sterile mask, and to assess the insertion site for any signs or symptoms of infection during central venous catheter dressing changes. Additionally, to prevent infection, TPN infusion tubing should be changed every 24 hours, and no single container of TPN should be hung for longer than 24 hours, with lipids not running for longer than 12 hours.
A patient who is scheduled for a skin test informs the nurse that he has been taking corticesteroids to help control his allergy symptoms. What nursing intervention should the nurse implement?
- A. The patient should take his corticosteroids regularly prior to testing.
- B. The patient should only be tested for grass, mold, and dust initially.
- C. The nurse should have an emergency cart available in case of anaphylaxis during the test.
- D. The patients test should be cancelled until he is off his corticosteroids.
Correct Answer: A
Rationale: The patient should continue taking his corticosteroids regularly prior to testing. Corticosteroids can suppress the body's immune response and affect the results of skin tests by potentially causing a false-negative result. Instructing the patient to maintain his regular corticosteroid regimen will help ensure accurate testing results. It is essential to consult with the healthcare provider to determine the appropriate timing for testing in relation to corticosteroid use.
The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse?
- A. A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away.
- B. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.
- C. A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away.
- D. A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away.
Correct Answer: A
Rationale: A person whose vision is measured at 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. In this measurement system, the first number represents how far away the person is from the eye chart (the testing distance), and the second number indicates how far away a person with normal vision can be from the chart to see the same line of letters or objects. Therefore, if someone has 20/40 vision, it means they need to be at 20 feet to see what a person with 20/20 vision can see at 40 feet.
The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work? What would be the nurses best response?
- A. Yes, its known to have a slight protective effect.
- B. Yes, but studies also show an increased risk of osteoporosis.
- C. You wont need to worry about getting cancer as long as you take Tamoxifen.
- D. Tamoxifen is known to be a highly effective protective measure.
Correct Answer: A
Rationale: The nurse's best response should be to provide accurate information and manage the patient's expectations realistically. Tamoxifen is known to have a slight protective effect in reducing the risk of developing breast cancer in high-risk individuals like the patient in the scenario. However, it is not a guarantee against developing breast cancer. It is essential for the nurse to convey this information to the patient to ensure that she understands the benefits and limitations of Tamoxifen therapy. Additionally, discussing potential side effects and risks associated with Tamoxifen, such as an increased risk of osteoporosis, is important for the patient to make an informed decision about her health care.
For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to
- A. 6:30 AM on January 13
- B. 6:30 PM on January 13
- C. 6:30 PM on January 14
- D. 6:30 AM on January 15
Correct Answer: A
Rationale: Rho(D) immune globulin (RhoGAM) needs to be administered within 72 hours postpartum to Rh-negative patients who have given birth to Rh-positive infants to prevent Rh sensitization. The patient delivered at 6:30 AM on January 10, so the RhoGAM should be administered prior to that time on January 13, which is 72 hours postpartum. Therefore, the correct choice is A. 6:30 AM on January 10.