Nokea
An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer?
- A. Corticosteroids
- B. Gamma globulin
- C. Hepatitis B vaccine
- D. Fresh frozen plasma
Correct Answer: B
Rationale: The correct answer is B: Gamma globulin. Gamma globulin contains antibodies that can provide immediate passive immunity against hepatitis B virus. Administering corticosteroids (A) would not protect against hepatitis B infection. Hepatitis B vaccine (C) is used for prevention, not immediate protection. Fresh frozen plasma (D) does not contain specific antibodies against hepatitis B.
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What instructions should the nurse give to a patient with cervical cancer who is planned to receive external-beam radiation to prevent complications from the effects of the radiation?
- A. Test all stools for the presence of blood.
- B. Maintain a high-residue, high-fiber diet.
- C. Clean the perianal area carefully after every bowel movement.
- D. Inspect the mouth and throat daily for the appearance of thrush.
Correct Answer: C
Rationale: The correct answer is C: Clean the perianal area carefully after every bowel movement. This is important to prevent skin breakdown and infection due to the potential side effect of radiation-induced diarrhea. By maintaining good hygiene in the perianal area, the patient can reduce the risk of complications such as skin irritation and infection.
Choice A is incorrect because testing stools for the presence of blood is not directly related to preventing complications from external-beam radiation.
Choice B is incorrect because while a high-residue, high-fiber diet may be beneficial for some cancer patients, it is not specifically recommended to prevent complications from radiation therapy in this case.
Choice D is incorrect because inspecting the mouth and throat daily for thrush is more relevant for patients receiving chemotherapy or immunosuppressive therapy, not specifically for those undergoing external-beam radiation.
A patient with gout is prescribed allopurinol. What should the nurse include in the patient teaching?
- A. Take the medication with food.
- B. Increase intake of high-purine foods.
- C. Limit fluid intake to 1 liter per day.
- D. Expect immediate pain relief.
Correct Answer: A
Rationale: The correct answer is A: Take the medication with food. Allopurinol can cause stomach upset, so taking it with food can help minimize gastrointestinal side effects. Taking it on an empty stomach may increase the risk of nausea or stomach pain. Choice B is incorrect because increasing high-purine foods can exacerbate gout symptoms. Choice C is incorrect because limiting fluid intake can lead to dehydration, which is not recommended for gout patients. Choice D is incorrect because allopurinol does not provide immediate pain relief; it works to lower uric acid levels over time to prevent gout attacks.
The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?
- A. Drowsiness.
- B. Itching.
- C. Nausea.
- D. Respiratory rate of 8 breaths per minute.
Correct Answer: D
Rationale: The correct answer is D: Respiratory rate of 8 breaths per minute. A respiratory rate of 8 breaths per minute indicates respiratory depression, a serious side effect of morphine that can lead to respiratory arrest. Immediate intervention is crucial to prevent further complications, such as hypoxia and respiratory failure. Drowsiness, itching, and nausea are common side effects of morphine but are not life-threatening like respiratory depression. Monitoring and managing respiratory status is the top priority to ensure the client's safety and well-being.
A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. Bleeding time
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is used to monitor the effectiveness of heparin therapy because heparin primarily affects the intrinsic pathway of the coagulation cascade, which is reflected in the PTT results. Monitoring PTT helps to ensure that the patient's blood is within the therapeutic range for anticoagulation.
A: Prothrombin time (PT) is used to monitor warfarin therapy, which affects the extrinsic pathway of the coagulation cascade.
C: Bleeding time is not typically used to monitor heparin therapy effectiveness.
D: Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not directly reflect the effectiveness of heparin therapy in preventing or treating DVT.
A client with liver cirrhosis is prescribed lactulose. What is the purpose of this medication?
- A. To lower blood sugar levels
- B. To reduce ammonia levels
- C. To treat liver inflammation
- D. To improve bile flow
Correct Answer: B
Rationale: Rationale: Lactulose is prescribed for liver cirrhosis to reduce ammonia levels. It works by promoting the excretion of ammonia in the stool, preventing its accumulation in the bloodstream. This helps prevent hepatic encephalopathy, a serious complication of cirrhosis. Other choices are incorrect because lactulose does not directly affect blood sugar levels, liver inflammation, or bile flow in the context of liver cirrhosis.