Nokea
Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals
- A. HBsAg.
- B. anti-HBs
- C. anti-HBc IgG
- D. anti-HBc IgM.
Correct Answer: B
Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection. Choices A, C, and D are incorrect because: A) HBsAg indicates current infection with hepatitis B virus, C) anti-HBc IgG suggests past infection or immunity, and D) anti-HBc IgM is a marker of acute hepatitis B infection.
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A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?
- A. Back Pain
- B. Fever and Chills
- C. Risk for Bleeding
- D. Dizziness
Correct Answer: C
Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.
A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?
- A. Restrict daily dietary protein intake.
- B. Reposition the patient every 4 hours.
- C. Place the patient on a pressure-relieving mattress.
- D. Perform passive range of motion daily.
Correct Answer: C
Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.
The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?
- A. Offer psychological support for depression.
- B. Offer high-calorie, high-protein dietary choices.
- C. Administer prescribed opioids to relieve pain as needed.
- D. Teach about the need to avoid scratching any pruritic areas.
Correct Answer: C
Rationale: The correct answer is to administer prescribed opioids to relieve pain as needed. Pain management is the highest priority in this scenario as effective pain control is essential for the patient's overall well-being. Pain relief will not only improve the patient's comfort but also enhance their ability to eat, follow dietary recommendations, and be open to psychological support. Offering psychological support for depression (Choice A) is important but addressing pain takes precedence. While providing high-calorie, high-protein dietary choices (Choice B) is crucial, it is secondary to managing pain. Teaching about the need to avoid scratching pruritic areas (Choice D) is relevant but not the highest priority in this situation where pain management is critical for the patient's quality of life.
A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?
- A. Hemoglobin of 11 g/dl
- B. Platelet count of 150,000
- C. INR of 2.5
- D. Potassium of 2.7 mEq/L
Correct Answer: D
Rationale: The critical lab result that should be reported to the physician immediately in this case is the potassium level of 2.7 mEq/L. A potassium imbalance, especially in a patient with a history of dysrhythmia like atrial fibrillation, can be life-threatening and lead to cardiac distress. Low potassium levels (hypokalemia) can predispose the patient to dangerous arrhythmias, including worsening atrial fibrillation. Hemoglobin of 11 g/dl, platelet count of 150,000, and an INR of 2.5 are within acceptable ranges and not as immediately concerning as a low potassium level in this clinical context.
During the admission assessment of a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate due to this condition?
- A. "I have constant blurred vision."?
- B. "I can't see on my left side."?
- C. "I have to turn my head to see my room."?
- D. "I have specks floating in my eyes."?
Correct Answer: C
Rationale: In chronic bilateral glaucoma, peripheral visual field loss occurs due to elevated intraocular pressure, leading to the need to turn the head to compensate for the visual field deficit. This symptom is characteristic of advanced glaucoma. Choice A is incorrect as constant blurred vision is a common symptom but not specific to peripheral vision loss in glaucoma. Choice B is incorrect because specific visual field deficits are more common than complete loss on one side. Choice D is incorrect as seeing floaters (specks floating in the eyes) is associated with other eye conditions like posterior vitreous detachment, not glaucoma.