Nokea
A patient is receiving opioids for pain. Which bowel assessment is a priority?
- A. Clostridium difficile
- B. Constipation
- C. Hemorrhoids
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is B: Constipation. When a patient is receiving opioids, constipation is a common side effect due to decreased gut motility. It is a priority assessment because untreated constipation can lead to serious complications such as bowel obstruction. Monitoring for constipation allows for early intervention with stool softeners or laxatives to prevent complications.
Incorrect choices:
A: Clostridium difficile - While important to consider in patients on antibiotics, it is not directly related to opioid use.
C: Hemorrhoids - Although opioids can contribute to constipation which may exacerbate hemorrhoids, it is not the priority assessment.
D: Diarrhea - Opioids typically cause constipation, so diarrhea is less likely to be a priority concern in this scenario.
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When assessing patient with nutritional needs, which patients will require follow-up from the nurse?(Select all that apply.)
- A. A patient with infection taking tetracycline with milk
- B. A patient with irritable bowel syndrome increasing fiber
- C. A patient with diverticulitis following a high-fiber diet daily
- D. A patient with an enteral feeding and 500 mL of gastric residual
Correct Answer: A
Rationale: The correct answer is A: A patient with infection taking tetracycline with milk. This is because tetracycline binds with the calcium in milk, reducing its absorption and effectiveness. The nurse should follow up to ensure the patient is not compromising the treatment.
Choices B and C are incorrect because increasing fiber for irritable bowel syndrome and following a high-fiber diet for diverticulitis are appropriate interventions that do not require immediate follow-up.
Choice D is incorrect because it is a routine part of managing enteral feedings to monitor gastric residuals, and does not necessarily require immediate follow-up unless there are specific concerns.
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
- A. Salmonella infection
- B. Mycobacterium tuberculosis
- C. Clostridium difficile
- D. Pneumocystis pneumonia
Correct Answer: D
Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.
The nurse is teaching breast self-examination (BSE) to a group of women. The nurse should recommend that the women perform BSE at what time?
- A. At the time of menses
- B. At any convenient time, regardless of cycles
- C. Weekly
- D. Between days 5 and 7 after menses
Correct Answer: A
Rationale: The correct answer is A: At the time of menses. This is because breasts are less lumpy and tender during this time, making it easier to detect abnormalities. Performing BSE at other times may lead to false alarms due to hormonal changes. Choice B is incorrect because timing matters for accurate results. Choice C is incorrect as weekly BSE is unnecessary and may cause unnecessary anxiety. Choice D is incorrect as breasts are more lumpy and tender post-menses, potentially making it harder to detect abnormalities.
A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow?
- A. The patient must not have received an immunization within 7 days.
- B. The nurse should administer albuterol 30 to 45 minutes prior to the test.
- C. Prophylactic epinephrine should be administered before the test.
- D. Emergency equipment should be readily available.
Correct Answer: D
Rationale: The correct answer is D. Having emergency equipment readily available is crucial during allergy skin testing as it can lead to severe allergic reactions. This precaution ensures prompt intervention in case of anaphylaxis. Other choices are incorrect because: A) Recent immunizations do not directly impact the skin testing process. B) Administering albuterol is not a standard pre-test requirement. C) Prophylactic epinephrine is not routinely given before allergy skin testing.
A student nurse is caring for a patient who has undergone a wide excision of the vulva. The student should know that what action is contraindicated in the immediate postoperative period?
- A. Placing patient in low Fowlers position
- B. Application of compression stockings
- C. Ambulation to a chair
- D. Provision of a low-residue diet
Correct Answer: B
Rationale: The correct answer is B: Application of compression stockings. Immediately after a wide excision of the vulva, compression stockings should be avoided as they can increase the risk of blood clots. Placing the patient in a low Fowler's position helps with comfort and promotes healing. Ambulation to a chair aids in preventing complications like pneumonia and deep vein thrombosis. Providing a low-residue diet is appropriate postoperatively to prevent straining during bowel movements.