Nokea
A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct Answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
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Which of the following interventions is considered the most effective form of universal precautions?
- A. Cap all used needles before removing them from their syringes
- B. Discard all used uncapped needles and syringes in an impenetrable protective container
- C. Wear gloves when administering IM injections
- D. Follow enteric precautions
Correct Answer: B
Rationale: The most effective form of universal precautions is to discard all used uncapped needles and syringes in an impenetrable protective container. This practice minimizes the risk of needle-stick injuries, which are a significant concern when dealing with used needles. By safely disposing of uncapped needles, healthcare providers can protect themselves and others from potential exposure to bloodborne pathogens.
If a healthcare provider administers an injection to a patient who refuses, they have committed:
- A. Assault and battery
- B. Negligence
- C. Malpractice
- D. None of the above
Correct Answer: A
Rationale: When a healthcare provider administers treatment, such as an injection, against a patient's refusal or will, it constitutes assault and battery. Assault refers to the intentional act that causes a person to fear that they will be touched without consent, while battery involves the actual harmful or offensive contact. In this scenario, administering the injection without the patient's consent is both an assault (causing fear of unwanted contact) and a battery (unwanted physical contact). Therefore, the correct answer is 'Assault and battery.' Negligence refers to a failure to exercise the appropriate level of care expected in a situation, while malpractice involves professional negligence or misconduct.
Which natural body defense plays an active role in preventing infection?
- A. Yawning
- B. Body hair
- C. Hiccupping
- D. Rapid eye movements
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
- A. Instructing the patient about this diagnostic test
- B. Writing the order for this test
- C. Giving the patient breakfast
- D. All of the above
Correct Answer: A
Rationale: The nurse's responsibility in this scenario is to instruct the patient about the diagnostic test ordered by the physician. This includes explaining the purpose of the test, any necessary preparations, and what to expect. The nurse is not responsible for writing the order, as this is the physician's role. Additionally, providing breakfast is not directly related to the platelet count test. Therefore, the correct answer is A, which aligns with the nurse's role in educating and supporting the patient regarding the test.
Examples of patients suffering from impaired awareness include all of the following except:
- A. A semiconscious or overfatigued patient
- B. A disoriented or confused patient
- C. A patient who cannot care for themselves at home
- D. A patient demonstrating symptoms of drug or alcohol withdrawal
Correct Answer: C
Rationale: Patients with impaired awareness may exhibit symptoms such as being semiconscious, overfatigued, disoriented, confused, or demonstrating symptoms of drug or alcohol withdrawal. A patient who cannot care for themselves at home does not necessarily indicate impaired awareness, as this could be due to physical limitations or lack of support, rather than a cognitive deficit.