Nokea
Take home medications given to Patient Lily includes digitalis therapy which was given to patient since she was pregnant. Which of the following would the nurse anticipate with patient's drug therapy?
- A. Switching to a more potent drug.
- B. Continuation of the same dosage.
- C. Need for change in medication.
- D. Addition of diuretic to the regimen.
Correct Answer: B
Rationale: Digitalis therapy, commonly prescribed for heart conditions, is known for its narrow therapeutic range and potential for toxicity. In the case of Patient Lily, who has been on digitalis therapy since she was pregnant, the nurse would anticipate the continuation of the same dosage to maintain the therapeutic effects and reduce the risks of toxicity. It is essential to monitor the patient's digitalis levels regularly and adjust the dosage if necessary based on the patient's response and any changes in their clinical status. Switching to a more potent drug, changing the medication, or adding a diuretic would not be appropriate without further assessment and consultation with the healthcare provider managing Lily's digitalis therapy.
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Which of the following is a common clinical manifestation of osteoarthritis in the hip joint?
- A. Baker's cyst
- B. Heberden's nodes
- C. Trendelenburg gait
- D. Swan-neck deformity
Correct Answer: C
Rationale: Osteoarthritis in the hip joint can lead to weakness or dysfunction in the hip abductor muscles, causing a Trendelenburg gait. This gait abnormality is characterized by a dropping of the pelvis on the opposite side of the affected hip during weight-bearing on the affected leg. It is a common clinical manifestation of hip osteoarthritis due to the muscle weakness and altered mechanics in the hip joint. Baker's cyst is associated with knee osteoarthritis, Heberden's nodes are commonly seen in osteoarthritis of the fingers, and Swan-neck deformity is typically seen in rheumatoid arthritis, not osteoarthritis.
A primigravida at 40 weeks gestation is in active labor. The nurse notes late decelerations on the fetal monitor tracing. What action should the nurse take first?
- A. Administer oxygen to the mother.
- B. Change the mother's position.
- C. Prepare for immediate delivery.
- D. Discontinue oxytocin infusion.
Correct Answer: D
Rationale: Late decelerations on the fetal monitor tracing indicate a potential uteroplacental insufficiency, which could be caused by decreased oxygen supply to the fetus. One common cause of late decelerations is uterine hyperstimulation due to excessive use of oxytocin. By discontinuing the oxytocin infusion, the nurse can help alleviate the stress on the fetus and decrease the likelihood of further late decelerations. This action should be prioritized before other interventions such as changing the mother's position or administering oxygen. Immediate delivery may be necessary if the fetus continues to show signs of distress despite discontinuing the oxytocin infusion.
Ms. Ruby 28 year old also a patient of Nurse Gladys is suffering from Rheumatic fever due to a previous streptococcal infection. In monitoring patient's status, the nurse should document which of the following TYPICAL manifestation EXCEPT ______.
- A. Increase body temperature
- B. Voluntary muscle spasm
- C. Non-pruritic rashes
- D. Migratory joint pains
Correct Answer: B
Rationale: In patients with Rheumatic fever, typical manifestations include an increase in body temperature, non-pruritic rashes, and migratory joint pains. Voluntary muscle spasm is not a typical manifestation of Rheumatic fever. The main clinical features of Rheumatic fever are related to the inflammation of the heart, joints, skin, and central nervous system. Muscle spasms are not a prominent feature of this condition. It is important for the nurse to be aware of these typical manifestations to effectively monitor and manage the patient's condition.
Mang Emilio refuses to take his daily medication for hypertension. Which of the following actions should Nurse Pedrito take at this time?
- A. Tell MangEmilio that he will suffer from stroke.
- B. Explore the reason for the client's refusal to take the medication.
- C. Administer the medication by injection.
- D. Obtain help from relatives in administering the medication.
Correct Answer: B
Rationale: The most appropriate action for Nurse Pedrito to take at this time is to explore the reason for Mang Emilio's refusal to take his daily medication for hypertension. By understanding the underlying cause of his refusal, Nurse Pedrito can address any concerns or barriers that may be preventing Mang Emilio from adhering to his medication regimen. This approach emphasizes the importance of patient-centered care and communication in promoting medication compliance and overall health outcomes. Additionally, it allows Nurse Pedrito to work collaboratively with Mang Emilio to find a solution that meets his needs and preferences.
During the surgical procedure, the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form. What should the nurse do?
- A. Proceed with the procedure as planned
- B. Document the discrepancy in the patient's chart
- C. Inform the surgeon and anesthesia provider immediately
- D. Request clarification from the patient and family members
Correct Answer: C
Rationale: If the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form, the immediate action should be to inform the surgeon and anesthesia provider. It is crucial to address any discrepancies before proceeding with the surgical procedure to ensure patient safety and prevent any potential errors or complications. The surgical team needs to be made aware of the issue so that they can verify the correct patient information and ensure that all necessary steps are taken to proceed safely. Communication and collaboration among the healthcare team members are essential in such situations to prevent any harm to the patient.