Nokea
A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem?
- A. Add protein powder to foods such as casseroles.
- B. Tell the patient to eat foods that are high in nutrition.
- C. Avoid giving the patient foods that are strongly disliked.
- D. Add spices to enhance the flavor of foods that are served.
Correct Answer: C
Rationale: Chemo twists taste bitter, metallic, off killing appetite. Skipping disliked foods sidesteps the cause, boosting intake over forcing nutrition or masking with protein or spices , which might flop. Nurses in oncology nail this tailoring to taste quirks beats generic fixes, tackling the root of this nutrition dip.
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When assigning staff to patients who are receiving chemotherapy, what is the major consideration about chemotherapeutic drugs?
- A. During preparation, drugs may be absorbed through the skin or inhaled
- B. Many chemotherapeutics are vesicants
- C. Chemotherapeutics are frequently given through central venous access devices
- D. Oral and venous routes are the most common
Correct Answer: A
Rationale: Chemotherapy's potency demands safety focus preparation risks skin absorption or inhalation, exposing staff to toxins, necessitating specialized training and protective gear. Vesicants, causing tissue damage if extravasated, are a concern, but preparation hazards affect all drugs, broader in scope. Central venous access is common but a procedural detail, not the primary staffing issue. Route prevalence is logistical, not safety-centric. Prioritizing exposure risk ensures staff handling mixing, drawing minimizes occupational harm, a legal and ethical imperative, shaping assignments to trained personnel, critical in chemotherapy's high-stakes delivery.
Which drug regimen in AIDS is usually used?
- A. 2 nucleosides and nevirapine
- B. 2 nucleosides and a protease inhibitor
- C. 1 nucleoside, nevirapine and a protease inhibitor
- D. A and B
Correct Answer: D
Rationale: AIDS cocktails two nucleosides plus nevirapine or protease inhibitor, both slam HIV's lifecycle. Single's weak nurses mix these chronic viral brakes.
The Lee Revised Cardiac Risk Index:
- A. Has been validated to predict the risk of mortality after major non-cardiac surgery.
- B. Is a complex algorithm.
- C. Provides a simple additive score incorporating six risk factors.
- D. Discriminates well between patients at moderate and severe risk of adverse cardiac outcome.
Correct Answer: C
Rationale: The Lee Revised Cardiac Risk Index (RCRI) predicts cardiac complications (e.g., myocardial infarction) after non-cardiac surgery. It's validated for morbidity, not mortality specifically, though it correlates with outcomes. It's not a complex algorithm but a straightforward tool: six factors (high-risk surgery, ischemic heart disease, heart failure, stroke/TIA, diabetes on insulin, renal insufficiency) are scored additively (0-6). This simplicity aids clinical use, providing risk percentages (e.g., 0.4% for 0 points, 11% for ≥3). It discriminates moderate-to-high risk well but less so at extremes. Age >70 isn't an automatic point; risk factors are specific. Its strength lies in its evidence-based, user-friendly design for perioperative cardiac risk stratification.
The family of a neutropenic client reports that the client is confused and 'is not acting right.' What action by the nurse is the priority?
- A. Delegate taking a set of vital signs
- B. Ask the client about pain
- C. Look at today's laboratory results
- D. Assess the client for a urinary tract infection
Correct Answer: A
Rationale: Neutropenia slashes immunity confusion screams infection, like sepsis, needing instant vitals to catch fever or shock, a priority delegated to flag danger fast per ABCs. Pain's a clue, but vitals trump. Labs lag; UTI assessment follows. Nurses lean on teamwork, ensuring rapid data in this infection-prone fog, a life-saving first step.
Assessment of a wound does not include which of the following?
- A. Location
- B. Size
- C. Blood Pressure
- D. Colour of wound
Correct Answer: C
Rationale: Wound checks where, how big, what hue guide care. BP's body-wide, not wound-specific. Nurses skip it, a chronic sore's focus.