Nokea
Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?
- A. Bruising around the operative site
- B. Pain
- C. Irritability
- D. Fever
Correct Answer: D
Rationale: Patients who have undergone splenectomy are at risk for overwhelming postsplenectomy infection (OPSI) due to the absence of a functioning spleen, which is important in fighting certain types of infections, especially those caused by encapsulated bacteria such as Streptococcus pneumoniae. Symptoms of OPSI can include fever, chills, weakness, and rapid breathing. Fever is a significant sign that alerts the nurse to the possibility of OPSI in a post-splenectomy patient, as it may indicate an infection that the body is struggling to fight without the spleen's immune support. This is a crucial symptom to monitor and act upon promptly to prevent serious complications in these individuals.
You may also like to solve these questions
What is the rationale for giving Mr. Franco frequent mouth care?
- A. He will be thirsty considering that he is doesn't drink enough fluids
- B. To remove dried blood when tongue is bitten during a seizure
- C. The tactile stimulation during mouth care will hasten return to consciousness
- D. Mouth breathing is used by comatose patient and it'll cause oral mucosa dying and cracking.
Correct Answer: B
Rationale: Giving Mr. Franco frequent mouth care is important to remove dried blood when the tongue is bitten during a seizure. Seizures can cause involuntary biting of the tongue, leading to the accumulation of dried blood in the mouth. If this blood is not removed promptly, it can result in discomfort, infection, and potential complications. Regular oral care helps maintain oral hygiene and prevents any issues related to oral trauma during seizures, promoting overall health and well-being for the patient.
The nurse understands that an anaphylactic reaction is considered which of the following types of hypersensitivity reactions?
- A. Type I
- B. Type III
- C. Type II
- D. Type IV
Correct Answer: A
Rationale: An anaphylactic reaction is considered a Type I hypersensitivity reaction. In Type I hypersensitivity, the immune system produces IgE antibodies in response to an allergen, leading to the release of various inflammatory mediators like histamine. This immediate systemic reaction can cause symptoms such as hives, itching, swelling, difficulty breathing, and in severe cases, anaphylactic shock. These reactions occur quickly, typically within minutes to hours after exposure to the allergen. Anaphylaxis is a medical emergency that warrants immediate intervention with epinephrine and supportive care.
The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient's face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.
Deaths have occurred when potassium chloride has been used incorrectly to flush a lock or central venous catheter. Which of the ff precautions should a nurse take to minimize this risk?
- A. Use a dilute form of potassium chloride before flushing locks
- B. Warm the KCL before flushing locks
- C. Read labels carefully on vials containing flush solutions for locks
- D. Replace the existing locks with new ones to avoid flushing
Correct Answer: C
Rationale: The precaution a nurse should take to minimize the risk of deaths occurring when potassium chloride is used incorrectly to flush a lock or central venous catheter is to read labels carefully on vials containing flush solutions for locks. This is essential to ensure that the correct solution is being used and to prevent accidental administration of potassium chloride, which can be fatal if used inappropriately. By carefully checking the labels, the nurse can confirm that they are using the correct flush solution and avoid any harmful errors. This simple precaution can help in ensuring patient safety and preventing adverse outcomes.
In Langerhans cell histiocytosis (LCH), all the following manifestations are at high risk of mortality in patients EXCEPT
- A. liver
- B. spleen
- C. lung
- D. hematopoietic system
Correct Answer: C
Rationale: Lung involvement, while serious, is less lethal compared to liver, spleen, or hematopoietic system involvement.