Nokea
For your patient with a CD4 count, less than 200, the most important nursing assessment would include
- A. Bowel movements.
- B. Urinary output.
- C. Fever.
- D. Blood pressure.
Correct Answer: C
Rationale: Fever can indicate opportunistic infections in immunocompromised patients.
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On the first postoperative day following a bowel resection, the patient complains of abdominal and incisional pain rated 9 on a scale of 0 to 10. Postoperative orders include morphine, 4 mg IV q2 hr, for pain and may repeat morphine, 4 mg IV, for breakthrough pain. The nurse determines that it has been only 2 hours since the last dose of morphine and wants to wait a little longer. What effect does the nurse’s action have on the patient?
- A. Protects the patient from addiction and toxic effects of the drug
- B. Prevents hastening or causing a patient’s death from respiratory dysfunction
- C. Contributes to unnecessary suffering and physical and psychosocial dysfunction
- D. Indicates that the nurse understands the adage of “start low and go slow” in administering analgesics
Correct Answer: C
Rationale: The correct answer is C. Delaying pain relief contributes to unnecessary suffering and can negatively impact recovery.
Identify the five rights of delegating nursing care (select all that apply).
- A. Right time
- B. Right task
- C. Right patient
- D. Right person
Correct Answer: B
Rationale: Effective delegation involves the right task, patient, person, circumstance, and supervision/evaluation.
List at least four factors in this situation that contribute to health disparities.
- A. Geographic isolation (living 'up the mountain')
- B. Limited access to healthcare (refusal of medical care)
- C. Low socioeconomic status (barely making a living)
- D. Lack of social support (children rarely visit)
Correct Answer: D
Rationale: Health disparities are influenced by geographic isolation, lack of access to healthcare, low socioeconomic status, and lack of social support. These factors collectively exacerbate her condition.
Prioritize them in order of severity.
- A. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating
- B. An 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days
- C. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week
- D. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour
Correct Answer: D
Rationale: A pulsating abdominal mass with sudden onset of pain suggests a possible abdominal aortic aneurysm, a life-threatening condition.
Many herbal products that are commonly taken cause surgical problems. Which herbs listed below should the nurse teach the patient to avoid before surgery to prevent an increase in bleeding for the surgical patient (select all that apply)?
- A. Garlic
- B. Fish oil
- C. Valerian
- D. Vitamin E, Astragalus, Ginkgo biloba
Correct Answer: D
Rationale: Herbs like garlic, fish oil, vitamin E, astragalus, and ginkgo biloba can increase bleeding risks and should be avoided before surgery.