Nokea
Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:
- A. Assess the involved extremity for color and temperature
- B. Check for capillary refill
- C. Evaluate pulse rate
- D. Do all of the above
Correct Answer: D
Rationale: The correct answer is D because assessing for localized ischemia involves evaluating multiple factors. A: Assessing color and temperature helps determine perfusion. B: Checking capillary refill assesses circulation. C: Evaluating pulse rate indicates cardiac output. Doing all of the above provides a comprehensive assessment of arterial flow and potential ischemia. Other choices are incorrect as they do not cover all aspects necessary for a thorough assessment.
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A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because it is important for the nurse to communicate directly with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter may undermine the patient's autonomy and dignity. It is crucial for the nurse to establish rapport and build a therapeutic relationship with the patient. Making eye contact with the patient (choice A) is a good nonverbal communication technique. Leaning forward while talking with the patient (choice C) shows attentiveness and engagement. Nodding periodically while the patient is speaking (choice D) demonstrates active listening and encourages the patient to continue sharing. However, speaking only to the patient's daughter (choice B) is the incorrect choice as it neglects the patient's role in the conversation and may lead to potential issues in communication and patient-centered care.
Which of the following is an appropriate nursing intervention to prevent infection in patients with AIDS?
- A. Prohibiting patients who are severely immunodeficient from having any visitors.
- B. Prohibiting visitors with a cough.
- C. Wearing protective gear such as gown, mask, gloves, and goggles when entering the room.
- D. Ensuring protective barrier isolation precautions are in place.
Correct Answer: C
Rationale: The correct answer is C. Wearing protective gear such as gown, mask, gloves, and goggles when entering the room is crucial to prevent infection in patients with AIDS. This intervention helps to minimize the risk of transmitting pathogens to the patient and vice versa. The protective gear acts as a barrier to prevent the spread of infectious agents. It also protects healthcare workers from exposure to potentially harmful pathogens.
Prohibiting visitors who are severely immunodeficient (choice A) may be isolating for the patient and does not directly address preventing infection transmission. Prohibiting visitors with a cough (choice B) is important but does not cover all potential sources of infection. Ensuring protective barrier isolation precautions are in place (choice D) is a general statement and does not specify the practical steps needed to prevent infection transmission effectively.
Which of the ff. statements, if made by a patient with hypertension, indicates to a nurse a need for more teaching?
- A. “High BP may affect the kidneys and eyes.”
- B. “Most people with hypertension watch their diet.”
- C. “Medication will no longer be needed when I feel better.”
- D. “Many people do not know when their BP is high.”
Correct Answer: C
Rationale: Step-by-step rationale:
1. Statement C indicates a misunderstanding that medication can be stopped when feeling better, which is incorrect.
2. Hypertension is a chronic condition that often requires lifelong medication.
3. This demonstrates a lack of understanding regarding the necessity of long-term management.
4. Statements A, B, and D show knowledge about hypertension's effects, dietary management, and awareness, respectively.
Summary: Statement C is incorrect as it suggests stopping medication, while statements A, B, and D show accurate understanding of hypertension.
Which of the following immunoglobulins is first produced during an acute infection?
- A. IgG
- B. IgE
- C. IgM
- D. IgD
Correct Answer: C
Rationale: The correct answer is C: IgM. During an acute infection, the body's initial response is rapid and non-specific, leading to the production of IgM antibodies first. IgM is the first immunoglobulin class produced in response to a new antigen, providing immediate protection. IgG is produced later in the immune response and is responsible for long-term immunity. IgE is involved in allergic reactions and parasitic infections, not typically the first response to infection. IgD is primarily found on the surface of B cells and its function is not well understood in the context of acute infections.
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.