Nokea
Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
- A. document the onset, duration, severity, and precipitating factors
- B. may offer analgesics for chest pain
- C. administer oxygen via face mask
- D. inform the physician about the heaviness
Correct Answer: C
Rationale: The correct answer is C: administer oxygen via face mask. Given Aling Nena's sudden chest heaviness post-surgery, oxygen administration is the priority to ensure adequate oxygenation. This can help rule out potential respiratory issues or hypoxemia, which are common post-operatively. Providing oxygen promptly can prevent further complications such as respiratory distress or cardiac compromise. Documenting the pain characteristics (choice A) can be done after ensuring immediate physiological needs are met. Offering analgesics (choice B) without confirming the underlying cause can mask symptoms and delay appropriate interventions. Informing the physician (choice D) is important but not as urgent as addressing potential respiratory compromise.
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Then the drug is stopped. When should treatment resume?
- A. When the WBC falls to 5,000mm3
- B. When lost hair begins to grow back
- C. When the WBC count rises to 50,000/mm3
- D. When the client displays anemia
Correct Answer: A
Rationale: The correct answer is A: When the WBC falls to 5,000mm3. This is because a low WBC count indicates potential bone marrow suppression from the drug. Resuming treatment at this point ensures the bone marrow has recovered enough to handle the drug's effects.
Summary:
- Choice B: Hair regrowth is not a reliable indicator of bone marrow recovery.
- Choice C: A high WBC count suggests potential toxicity, not readiness for treatment.
- Choice D: Anemia is a late sign of bone marrow suppression, not an appropriate indicator to resume treatment.
Why must clients who will undergo diagnostic skin test avoid taking antihistamine or cold preparations for at least 48-72 hrs before testing?
- A. Antihistamines may increase the potential for excessive bleeding
- B. Antihistamines may aggravate the allergic reaction
- C. Antihistamines may increase the potential for false negative results
- D. Antihistamines may cause wheezing
Correct Answer: C
Rationale: The correct answer is C because antihistamines can suppress the immune response that the skin test is designed to detect, leading to false negative results. By inhibiting the body's allergic response, antihistamines can mask the presence of an allergy, giving the false impression that the individual is not allergic to a particular substance. This can lead to misdiagnosis and improper treatment. Choices A, B, and D are incorrect because antihistamines do not affect bleeding, aggravate allergic reactions, or cause wheezing in the context of a skin test.
Which of the ff. is a normal hemoglobin value?
- A. 38% to 48%
- B. 48 to 54 mg%
- C. 12 to 18 g/100mL
- D. 27 to 36 g/dL
Correct Answer: C
Rationale: The correct answer is C: 12 to 18 g/100mL. Normal hemoglobin values typically range from 12 to 18 g/100mL in adults. This range reflects the normal concentration of hemoglobin in the blood and is commonly used as a reference range in clinical practice. Choices A, B, and D are incorrect because they do not fall within the typical normal range for hemoglobin levels. Choice A (38% to 48%) is a percentage range, not a direct measurement of hemoglobin concentration. Choice B (48 to 54 mg%) and Choice D (27 to 36 g/dL) are outside the normal range for hemoglobin levels in adults. Therefore, the most appropriate and accurate choice among the options provided is C (12 to 18 g/100mL) based on standard reference values for hemoglobin concentration in the blood.
The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
- A. To gather data about a specific and current health problem.
- B. To identify life-threatening problems that require immediate attention.
- C. To compare and contrast current health status to baseline data.
- D. To establish a database to identify problems and strengths.
Correct Answer: D
Rationale: The correct answer is D: To establish a database to identify problems and strengths. This initial assessment is crucial for gathering comprehensive information about the client's health status, including past medical history, current health problems, and potential risk factors. By establishing a database, the nurse can identify both existing health issues that need to be addressed and strengths that can be built upon for effective care planning. This assessment serves as the foundation for developing an individualized care plan and monitoring the client's progress throughout their hospital stay.
Explanation of other options:
A: To gather data about a specific and current health problem - While this may be part of the assessment process, the main purpose is broader in scope to establish a comprehensive database.
B: To identify life-threatening problems that require immediate attention - While identifying urgent issues is important, the initial assessment is not solely focused on life-threatening problems.
C: To compare and contrast current health status to baseline data - While comparing to baseline data is important for tracking changes, the primary purpose
The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
- A. The nurse provides assistance while the patient is walking in the hallways.
- B. The patient is able to ambulate in the hallway with crutches.
- C. The patient will deny pain while walking in the hallway.
- D. The patient’s level of mobility will improve.
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery.
A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.