Nokea
Anaphylactic reaction after administering penicillin indicates
- A. An acquired atopic sensitization
- B. Passive immunity to penicillin allergen
- C. Antibodies to penicillin developed after earlier use of the drug
- D. Developed potent bivalent antibodies when the IV administration was started
Correct Answer: C
Rationale: Anaphylaxis is a severe IgE-mediated allergic reaction, occurring when prior penicillin exposure sensitizes the immune system, forming antibodies. Re-exposure triggers histamine release, causing symptoms like shock or dyspnea. Atopic sensitization relates to predisposition, not specific drug history. Passive immunity involves transferred antibodies, not self-developed ones. Bivalent antibodies forming during IV use is incorrect sensitization precedes administration. Nurses must assess allergy history, preparing for emergencies like epinephrine administration to reverse this life-threatening response.
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The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is difficulty breathing relieved by an upright position.
Nursing identifies its domain in a paradigm that includes:
- A. The person, health, environment/situation and nursing
- B. Concepts, theory, health and environment
- C. Health, person, environment and theory
- D. Nurses, physicians, models and client needs
Correct Answer: A
Rationale: Nursing's paradigm comprises person (client), health (well-being goal), environment/situation (context), and nursing (practice) a metaparadigm unifying theories like Nightingale's or Watson's. This defines nursing's scope, focusing on client care holistically. Concepts, theory, health, and environment are abstract, not a complete paradigm missing 'person' and 'nursing.' Health, person, environment, and theory swap 'nursing' for 'theory,' confusing framework with product. Nurses, physicians, models, and needs mix roles and tools, not core concepts. The person, health, environment, and nursing quartet encapsulates nursing's domain, guiding practice and research comprehensively.
The nurse is completing a health history with an older adult client who reveals smoking one pack of cigarettes daily for the past 50 years. Which illness prevention strategy should the nurse recommend?
- A. Referral to a smoking cessation program
- B. Screening for lung cancer
- C. Referral to a nutritionist
- D. Mobility exercises
Correct Answer: A
Rationale: For an older adult with a 50-year, pack-a-day smoking history, the nurse prioritizes illness prevention via a smoking cessation program referral primary prevention to halt further damage from a modifiable risk tied to lung cancer, COPD, and heart disease. Quitting slashes these risks studies show even late cessation improves lung function. Screening for lung cancer is secondary, detecting issues, not preventing them, though relevant later. Nutrition or mobility exercises enhance wellness but don't address smoking's root threat 20% of smokers develop COPD. Cessation directly targets the habit, aligning with nursing's preventive ethos, offering practical support like group therapy or nicotine aids. This strategy empowers the client to alter a decades-long risk, maximizing health gains despite age, a cornerstone of tailored care.
When charting in the client's record or chart, the nurse most needs to do which one of the following things?
- A. Date and sign each entry.
- B. Chart every two hours.
- C. Use ballpoint pen and not pencil.
- D. Cross out errors so others can't read them.
Correct Answer: A
Rationale: Dating and signing each chart entry is most essential, establishing a legal timeline and accountability for actions. Fixed intervals aren't mandatory, pens ensure permanence but aren't the priority, and crossing out errors risks misinterpretation. This practice validates care, crucial for nursing documentation integrity.
Anastacia Giron-Tupas was the first Filipino nurse to occupy the position of chief nurse in this hospital.
- A. St. Paul Hospital
- B. Iloilo Mission Hospital
- C. Philippine General Hospital
- D. St. Luke's Hospital
Correct Answer: C
Rationale: Anastacia Giron-Tupas, a pioneering Filipino nurse, became chief nurse at Philippine General Hospital, marking a milestone in local nursing leadership. Unlike St. Paul, Iloilo, or St. Luke's, PGH's prominence made her role significant, influencing professional advancement and recognition for Filipino nurses in the early 20th century.