Nokea
Parents of a newborn ask the nurse why vitamin K is being administered. The nurse accurately responds by explaining phytonadione (vitamin K) is administered to the newborn to:
- A. prevent bleeding.
- B. enhance immune response.
- C. prevent bacterial infection.
- D. maintain nutritional status.
Correct Answer: A
Rationale: Vitamin K is essential for the production of clotting factors in the liver. Newborns have lower levels of vitamin K and may not have a fully functioning clotting system, putting them at risk for bleeding disorders such as vitamin K deficiency bleeding (VKDB). Administering vitamin K to newborns helps prevent these bleeding issues and ensures proper clotting function. It does not have a direct effect on enhancing the immune response, preventing bacterial infections, or maintaining nutritional status, as its primary function in this context is to prevent bleeding disorders.
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Toni's disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Sexual activity
- C. Bowel management
- D. All of the above
Correct Answer: D
Rationale: When a patient's disease process involves the sacral plexus, such as in the case of Toni, it is important to assess aspects related to bladder problems, sexual activity, and bowel management. The sacral plexus plays a significant role in controlling functions such as bladder and bowel movements, as well as sexual function. Therefore, a comprehensive assessment including all of these areas is essential to provide holistic care for the patient and address any potential issues related to the sacral plexus involvement.
A 34 year old client is diagnosed with AIDS. His pharmacologic management includes zidovudine (AZT). During a home visit, the client states, "I don't understand how this medication works. Will it stop the infection?" What is the nurse's best response?
- A. The medication helps to slow the disease process, but it won't cure or stop it totally
- B. The medication blocks reverse transcriptase, the enzyme required fro HIV replication
- C. Don't you know? There aren't medication to stop or cure HIV
- D. No. it won't stop the infection. In fact, sometimes the HIV can become immune to the drug itself
Correct Answer: B
Rationale: The nurse's best response is, "The medication blocks reverse transcriptase, the enzyme required for HIV replication." This response provides the client with a clear and accurate explanation of how zidovudine (AZT) works. AZT is a nucleoside reverse transcriptase inhibitor (NRTI) that works by blocking the activity of reverse transcriptase, an enzyme needed for HIV replication. By inhibiting this enzyme, AZT helps to slow down the replication of the virus, reducing the viral load in the body and slowing the progression of the disease. It is important for the client to understand that while AZT can help manage HIV/AIDS, it is not a cure and will not completely eliminate the infection.
Nurse Karen is caring for a client with chronic renal failure. Which is a correct intervention for hyperkalemia?
- A. assess patient for fever and chest pain
- B. assess patient for muscle weakness, diarrhea and ECG changes
- C. encourage compliance with fluid restriction
- D. prepare patient for cardiac ultrasound
Correct Answer: B
Rationale: Hyperkalemia is a common complication in patients with chronic renal failure due to the kidneys' inability to excrete potassium efficiently. The correct intervention for hyperkalemia includes assessing the patient for muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common symptom of hyperkalemia due to its effects on neuromuscular function. Diarrhea can lead to potassium loss from the gastrointestinal tract, helping to lower potassium levels. ECG changes are essential to monitor in hyperkalemia as high potassium levels can result in life-threatening cardiac arrhythmias. By identifying these signs and symptoms early, appropriate interventions can be initiated promptly, such as administering medications to lower potassium levels or adjusting the patient's diet to limit potassium intake.
When the patient's signature is witnessed by the nurse on the surgical consent, which of the following does the nurse's signature indicate?
- A. The nurse obtained informed consent.
- B. The nurse provided informed consent.
- C. The nurse answered all surgical procedure questions.
- D. The nurse verified that the patient signed the consent.
Correct Answer: D
Rationale: The nurse's signature on the surgical consent form indicates that the nurse has verified and confirmed that the patient has signed the consent form. This step is crucial to ensure that the patient has voluntarily given their consent for the surgical procedure. It does not mean that the nurse obtained or provided informed consent, answered all surgical procedure questions, or made decisions on behalf of the patient. The nurse's role is to act as a witness to the patient's signature on the consent form to acknowledge that the patient has agreed to the procedure and signed the document.
Which of the following respiratory conditions is always considered a medical emergency?
- A. Asthma
- B. Cystic fibrosis (CF)
- C. Epiglottiditis
- D. Laryngotracheobronchitis (LTB)
Correct Answer: C
Rationale: Epiglottiditis is always considered a medical emergency due to the potential risk of airway obstruction. The epiglottis is a flap of tissue that prevents food and liquids from entering the airway during swallowing. If the epiglottis becomes inflamed or infected, it can swell and block the airway, making it difficult or impossible for the person to breathe. This obstruction can rapidly progress to a life-threatening situation if not treated promptly. Therefore, epiglottiditis requires immediate medical attention to ensure the airway remains open and the individual can breathe properly.