Nokea
Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
- A. "Your urine will be collected in a pouch following surgery."
- B. "You will have a nasogastric tube after surgery."
- C. "Your bowel will be visualized with a laparoscope during surgery."
- D. "You can drink liquids within 24 hours after surgery."
Correct Answer: A
Rationale: An ileostomy is a surgical procedure that involves creating a stoma from the ileum (part of the small intestine) to the abdominal wall, allowing waste to bypass the colon and exit the body through the stoma into a pouch worn on the outside of the body. Therefore, it is important for Nurse Beverly to inform Ian that his stool output will be collected in a pouch following the surgery. Option A is the correct choice as it directly relates to the postoperative care and management specific to an ileostomy procedure.
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For a client with sickle cell anemia, how does the nurse assess for jaundice?
- A. The nurse assesses mental status, verbal ability, and motor strength
- B. The nurse observes the joints for signs of swelling
- C. The nurse inspects the skin and sclera for jaundice
- D. The nurse collects a urine specimen
Correct Answer: C
Rationale: In a client with sickle cell anemia, jaundice is a common manifestation due to the breakdown of red blood cells. The nurse should inspect the skin and sclera for signs of jaundice, which presents as a yellow discoloration. This assessment helps in identifying the presence and severity of jaundice in the client, which can be indicative of ongoing hemolysis and the need for further interventions. Monitoring for jaundice is important in managing clients with sickle cell anemia to address complications early and provide appropriate care.
Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The normal range for platelets in adults is typically between 150,000 to 400,000 platelets per microliter of blood. A platelet count of 115,000/ul would be considered low, a condition known as thrombocytopenia. Thrombocytopenia can result in difficulty with blood clotting and may lead to increased risk of bleeding. Therefore, a platelet count of 115,000/ul would be identified as an abnormal finding by the nurse.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: Ketamine hydrochloride (Ketalar) is a dissociative anesthetic that can cause muscle rigidity and spasms as a side effect. This is known as a dose-dependent reaction to ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the client's safety and to provide appropriate management if this adverse effect occurs. It is essential for the nurse to closely observe the client for any signs of muscle rigidity and spasms after the administration of ketamine.
The most effective pharmacologic agent for the treatment of Parkinson's disease is:
- A. Levodopa
- B. Selegilene
- C. Permax
- D. Symmetrel
Correct Answer: A
Rationale: Levodopa is considered the most effective pharmacologic agent for the treatment of Parkinson's disease. Levodopa is a precursor of dopamine, a neurotransmitter that is deficient in Parkinson's disease. By increasing dopamine levels in the brain, levodopa helps to alleviate the motor symptoms of Parkinson's disease, such as tremors, stiffness, and slowness of movement. Levodopa is often combined with another medication called carbidopa to enhance its effectiveness and reduce side effects. While other medications like selegiline, pergolide (Permax), and amantadine (Symmetrel) can also be used to manage Parkinson's disease symptoms, levodopa remains the primary and most effective treatment option for many patients.
Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:
- A. Kaposi's Sarcoma
- B. Pneumonia Carnii
- C. Filterable Virus
- D. Staphylococcus bacteria
Correct Answer: B
Rationale: Pulmonary complications are the most common problem in caring for AIDS patients due to Pneumocystis pneumonia, also known as Pneumocystis jirovecii pneumonia or PCP. PCP is an opportunistic infection caused by the fungus Pneumocystis jirovecii, previously known as Pneumocystis carinii. This particular type of pneumonia is a prevalent and potentially life-threatening infection in individuals with weakened immune systems, such as those with AIDS. PCP is a major cause of morbidity and mortality in AIDS patients due to the compromised immune system's inability to effectively fight off the infection. Prompt diagnosis and treatment of PCP are crucial in the care of AIDS patients to improve outcomes and reduce the risk of respiratory complications.