Nokea
A woman sees her primary care provider because of extreme fatigue for the past 2 months; she difficulty lifting even light objects. Her physician suspects myasthenia gravis. Which of the ff. tests should the nurse anticipate to confirm this diagnosis?
- A. Mestinon test
- B. Pulmonary function studies
- C. Quinine tolerance test
- D. Tensilon test
Correct Answer: D
Rationale: The correct answer is D: Tensilon test. The Tensilon test involves administering edrophonium (Tensilon) to temporarily improve muscle weakness in myasthenia gravis patients, confirming the diagnosis. Other choices are incorrect: A (Mestinon test) is not a standard diagnostic test for myasthenia gravis, B (Pulmonary function studies) are not specific for myasthenia gravis, and C (Quinine tolerance test) is not a relevant test for this condition.
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Which action best demonstrates the nurse’s role in ensuring continuity of care during the evaluation phase?
- A. Rewriting the care plan based on current findings.
- B. Communicating the client’s progress to the interdisciplinary team.
- C. Reassessing the client to gather additional data.
- D. Providing emotional support to the client and family.
Correct Answer: B
Rationale: The correct answer is B: Communicating the client’s progress to the interdisciplinary team. During the evaluation phase, the nurse plays a crucial role in ensuring continuity of care by effectively communicating the client’s progress to the interdisciplinary team. This action allows for collaborative decision-making based on the latest information, promotes coordination of care, and ensures that all team members are informed and involved in the client's care plan. Rewriting the care plan (A) is important but may not be the most immediate action during the evaluation phase. Reassessing the client (C) is valuable for gathering additional data but may not directly contribute to continuity of care during this phase. Providing emotional support (D) is essential but may not specifically address continuity of care during evaluation.
Which instruction about insulin administration should the nurse give to a client?
- A. “Always follow the same order when drawing the different insulin into the syringe.”
- B. “Shake the vial before withdrawing the insulin.”
- C. “Store unopened vials of insulin in the freezer at temperatures well below freezing.”
- D. “Discard the intermediate-acting insulin if it disappears cloudy.”
Correct Answer: A
Rationale: The correct answer is A because maintaining consistency in the order of drawing different types of insulin into the syringe helps prevent medication errors. When mixing insulins, drawing them in the same sequence ensures the correct dose and prevents contamination.
Explanation:
A: Following the same order ensures accurate dosing and minimizes the risk of mixing up insulins.
B: Shaking the vial can cause air bubbles which can affect the accuracy of the dose.
C: Storing insulin in the freezer can damage the medication and alter its effectiveness.
D: Cloudiness in intermediate-acting insulin is normal and does not indicate it should be discarded.
An adult who has gastroenteritis and is on digitalis ha lab values of: K 3.2 mEq/L, Na 136 mEq/L, Ca 8.8 mg/dl, and Cl 98 mEq/L. the nurse puts which of the following on the client’s plan of care?
- A. Stop digitalis therapy
- B. Observe for trousseau’s and chovestek’s
- C. Avoid foods rich in potassium signs
- D. Observe for digitalis toxicity
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. The lab value of K at 3.2 mEq/L indicates hypokalemia.
2. Digitalis can worsen hypokalemia and lead to toxicity.
3. Avoiding foods rich in potassium will prevent further lowering of potassium levels.
4. This intervention helps prevent potential digitalis toxicity in the client.
Summary of why the other choices are incorrect:
A. Stopping digitalis therapy abruptly can lead to rebound effects and worsen the condition.
B. Trousseau's and Chvostek's signs are not relevant to the client's current lab values.
D. While observing for digitalis toxicity is important, addressing the low potassium level is a more immediate concern in this scenario.
The cause of death of most AIDS patients who develop multiple opportunistic infections is/are the following: a.Weakened immune system impairs response to therapy
- A. AH of these (a, b, c)
- B. Weakened immune system impairs resistance to infection
- C. Infection cannot be treated effectively
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Most AIDS patients with multiple opportunistic infections die due to a weakened immune system impairing response to therapy. When the immune system is compromised, the body struggles to fight off infections effectively, even with treatment. This results in the infections becoming more severe and ultimately leading to death.
Summary of Other Choices:
B: Weakened immune system impairs resistance to infection - While this is true, it doesn’t directly address the cause of death in AIDS patients with multiple infections.
C: Infection cannot be treated effectively - This is not entirely accurate as infections can be treated, but the weakened immune system hinders the response to treatment.
Overall, Choice A is the most accurate as it directly links the weakened immune system to the inability to respond effectively to therapy, leading to fatal outcomes.
A hospital’s wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient’s dressing changes. Which action should the nurses take next?
- A. Include dressing change instructions and frequency in the care plan.
- B. Assume that the wound nurse will perform all dressing changes.
- C. Request that the health care provider look at the wound.
- D. Encourage the patient to perform the dressing changes.
Correct Answer: A
Rationale: The correct answer is A: Include dressing change instructions and frequency in the care plan. This is the correct action because it ensures consistency in care and communication among the nursing team. By documenting the dressing change instructions and frequency in the care plan, all nurses will have clear guidance on how to perform the dressing changes correctly and at the appropriate intervals. This promotes continuity of care and helps prevent errors or omissions in the dressing change process.
Option B is incorrect as it is not realistic to expect the wound nurse to perform all dressing changes. Option C is unnecessary unless there are specific concerns requiring the health care provider's attention. Option D is not appropriate as encouraging the patient to perform dressing changes may not be safe or feasible depending on the patient's condition.