Nokea
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: Lumbar pain during a blood transfusion can be a sign of an adverse reaction, such as a transfusion reaction. Any complaints of pain during a transfusion should not be ignored. In this case, the nurse should first stop the transfusion to prevent any further complications. The client should be assessed promptly for other signs of a transfusion reaction, and appropriate actions should be taken as needed to ensure the client's safety and well-being.
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Which finding requires immediate attention in a child with glomerulonephritis?
- A. Sleeping most of the day with BP 170/90.
- B. Urine output of 190 mL in 8 hours with Coca-Cola-colored urine.
- C. Severe headache and photophobia.
- D. Refusal to eat with poor appetite.
Correct Answer: C
Rationale: A severe headache with photophobia may indicate hypertensive encephalopathy; this requires prompt evaluation.
What is an appropriate screening test for hearing that can be administered by the nurse to a 5- year-old child?
- A. The Rinne test
- B. The Weber test
- C. Conventional audiometry
- D. Eliciting the startle reflex
Correct Answer: C
Rationale: Conventional audiometry is the appropriate screening test for hearing that can be administered by a nurse to a 5-year-old child. This test involves using specialized equipment to measure the child's ability to hear sounds at various frequencies and volumes. It is a comprehensive and reliable test that can accurately assess the child's hearing abilities across the auditory spectrum. The other options listed (A. Rinne test, B. Weber test, and D. Eliciting the startle reflex) are not suitable for screening the hearing of a 5-year-old child as they are either more applicable to adults or not as comprehensive and reliable as conventional audiometry when assessing hearing in children.
Which term best describes the identification of the distribution and causes of disease, injury, or illness?
- A. Nursing process
- B. Epidemiologic process
- C. Community-based statistics
- D. Mortality and morbidity statistics
Correct Answer: B
Rationale: The term that best describes the identification of the distribution and causes of disease, injury, or illness is the epidemiologic process. Epidemiology is the study of the patterns, causes, and effects of health and disease conditions in populations. Through the epidemiologic process, health professionals can investigate and understand the distribution of diseases, determine risk factors, and develop strategies for prevention and control. Nursing process refers to the systematic method nurses use to provide patient-centered care. Community-based statistics are data collected from a specific community for various purposes. Mortality and morbidity statistics provide information on deaths and disease rates but do not encompass the comprehensive approach of the epidemiologic process in understanding the causes and distribution of diseases.
A client asks nurse Carlos the rationale for giving multi-drug treatment for tuberculosis. Which is an appropriate response?
- A. multiple drugs allow reduced levels of drugs to be given
- B. multiple drugs reduce undesirable drug side-effect
- C. multiple drugs potentiate the action fo the drugs
- D. multiple drugs reduce development of resistant strains of the bacteria
Correct Answer: D
Rationale: Giving multiple drugs for the treatment of tuberculosis is essential because it helps reduce the development of resistant strains of the bacteria. Tuberculosis is caused by Mycobacterium tuberculosis, which has the potential to develop resistance to single drug therapy through genetic mutations. The use of multiple drugs in combination therapy prevents the bacteria from developing resistance since they work through different mechanisms of action, making it harder for the bacteria to adapt and survive. This approach is known as Directly Observed Treatment, Short-course (DOTS), and it is an effective strategy recommended by the World Health Organization to combat the rising issue of drug-resistant tuberculosis.
Which of the following tests would the nurse use as an initial screening test to determine hearing loss?
- A. Romberg test
- B. Caloric test
- C. Otoscopic examination
- D. Whisper voice test
Correct Answer: D
Rationale: The nurse would use the whisper voice test as an initial screening test to determine hearing loss. This test involves the nurse whispering a series of words or numbers from a distance behind the patient to assess their ability to hear and repeat the whispered words accurately. This test is quick, easy, and can be performed in a quiet environment without the need for special equipment, making it an effective initial screening tool for hearing loss. The Romberg test assesses balance, the caloric test evaluates vestibular function, and the otoscopic examination is used to assess the external ear canal and eardrum, but none of these tests specifically assess hearing loss.