Nokea
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?
- A. Blood pressure (BP) is less than 140/90 mm Hg.
- B. Patient reports decreased exertional dyspnea
- C. Heart rate is between 60 and 100 beats/minute
- D. Patient's chest x-ray indicates clear lung fields
Correct Answer: B
Rationale: The correct answer is for the patient to report decreased exertional dyspnea. In idiopathic pulmonary arterial hypertension (IPAH), exertional dyspnea is a significant symptom indicating disease severity. Improvement in this symptom suggests that the medication, nifedipine, is effective in managing the condition. While nifedipine can affect blood pressure (choice A) and heart rate (choice C), these parameters are not specific indicators for monitoring IPAH improvement. Choice D, clear lung fields on the chest x-ray, does not directly correlate with the effectiveness of therapy for IPAH. Therefore, the most relevant assessment to monitor improvement in a patient with IPAH receiving nifedipine is a decrease in exertional dyspnea.
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A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?
- A. Now I know my baby will need a cesarean section.
- B. My baby will need two shots soon after birth.
- C. I will not be able to breastfeed.
- D. My baby's father does not need testing; I know I am the one with hepatitis.
Correct Answer: B
Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.
Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?
- A. Teach the patient to avoid using over-the-counter expectorants.
- B. Assist the patient with chest physiotherapy and postural drainage.
- C. Notify the healthcare provider immediately regarding any bloody or foul-smelling sputum.
- D. Teach about the necessity of prolonged antibiotic therapy after discharge from the hospital.
Correct Answer: D
Rationale: For a patient diagnosed with a lung abscess, the priority intervention is to educate them about the importance of prolonged antibiotic therapy post-hospital discharge. Long-term antibiotic treatment is crucial for eradicating the infecting organisms in a lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess as they can potentially spread the infection. While foul-smelling and bloody sputum are common in lung abscess, immediate notification to the healthcare provider is essential. Avoiding the use of over-the-counter expectorants is not necessary, as expectorants can be used to facilitate coughing and clearing of secretions in this condition.
A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:
- A. Hypotriglyceridemia
- B. Abdominal hernia
- C. Anorexia
- D. Peritonitis
Correct Answer: A
Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
- A. Yellow-tinged skin
- B. Orange-colored sputum
- C. Thickening of the fingernails
- D. Difficulty hearing high-pitched voices
Correct Answer: A
Rationale: The correct answer is 'Yellow-tinged skin.' Yellow-tinged skin is indicative of noninfectious hepatitis, a toxic effect of isoniazid (INH), rifampin, and pyrazinamide. If a patient on TB therapy develops hepatotoxicity, alternative medications will be necessary. Thickening of fingernails and difficulty hearing high-pitched voices are not typical side effects of the medications used in standard TB therapy. Presbycusis, age-related hearing loss, is common in older adults and not a cause for immediate concern. Orange-colored sputum is an expected side effect of rifampin and does not warrant immediate notification to the healthcare provider.
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
- A. Paradoxic chest movement
- B. Complaint of chest wall pain
- C. Heart rate of 110 beats/minute
- D. Large bruised area on the chest
Correct Answer: A
Rationale: Paradoxic chest movement is the most concerning finding as it indicates a potential flail chest, which can lead to severe compromise in gas exchange and rapid hypoxemia. This condition requires immediate attention to prevent respiratory distress. Complaint of chest wall pain, a slightly elevated heart rate, and a large bruised area on the chest are important assessment findings but may not immediately threaten gas exchange or respiratory function. Therefore, identifying paradoxic chest movement is critical for prompt intervention and management.