Nokea
The INITIAL priority assessment performed by the nurse, when admitting a patients the unit after abdominal surgery is to check for ______.
- A. surgical site for drainage and hemorrhage
- B. skin color and temperature
- C. responsiveness to painful stimuli and noise
- D. respiratory function and airway
Correct Answer: D
Rationale: When admitting a patient to the unit after abdominal surgery, the initial priority assessment performed by the nurse should focus on assessing the patient's respiratory function and airway. This is crucial because post-surgical patients are at risk for complications such as respiratory depression, atelectasis, and airway obstruction. Monitoring the patient's breathing pattern, oxygen saturation levels, and ensuring a patent airway are essential in preventing respiratory distress or failure. Prompt assessment and intervention in this area can help prevent respiratory complications and ensure the patient's safety and well-being. Once the patient's respiratory status is stable, the nurse can then proceed to assess other aspects such as the surgical site, skin color, temperature, and responsiveness to stimuli.
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A patient is prescribed a proton pump inhibitor (PPI) for the treatment of gastroesophageal reflux disease (GERD). Which instruction should the nurse include in patient education about PPI therapy?
- A. "Take the medication with antacids for enhanced effectiveness."
- B. "Avoid consuming citrus fruits while on PPI therapy."
- C. "Take the medication 30 minutes before meals."
- D. "Report any signs of gastrointestinal bleeding promptly."
Correct Answer: C
Rationale: Patients prescribed proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD) should be instructed to take the medication 30 minutes before meals. This is because PPIs work best when taken on an empty stomach, allowing them to inhibit the gastric proton pump effectively and reduce acid production in anticipation of food intake. Taking the medication before meals ensures optimal absorption and effectiveness in controlling symptoms of GERD.
A woman in active labor is receiving intravenous magnesium sulfate for the prevention of eclampsia. What maternal assessment finding indicates magnesium toxicity?
- A. Muscle weakness
- B. Increased deep tendon reflexes
- C. Hypotension
- D. Tachycardia
Correct Answer: B
Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.
The QA team was alerted by the Administration, that they have to anticipate for a possible earthquake in the forthcoming days. As part of Safe Practice Environment (SPE) standards, which of the following are to be given PRIORITY attention by the team? I Electrical wires II Combustible materials III Entry, Exit of the building IV Infected waste materials
- A. I, II, III & IV
- B. I & II
- C. II and II
- D. I, II & III
Correct Answer: B
Rationale: In preparing for a possible earthquake as part of Safe Practice Environment (SPE) standards, the QA team should prioritize attention on Electrical wires (I) and Combustible materials (II).
A patient with a history of multiple myeloma presents with weakness, bone pain, and recurrent infections. Laboratory tests reveal anemia, hypercalcemia, renal insufficiency, and monoclonal spike on serum protein electrophoresis. Which of the following conditions is most likely to cause these findings?
- A. Waldenstrom macroglobulinemia
- B. Hodgkin lymphoma
- C. Chronic lymphocytic leukemia (CLL)
- D. Multiple myeloma
Correct Answer: D
Rationale: Multiple myeloma is a plasma cell neoplasm characterized by the presence of abnormal monoclonal plasma cells in the bone marrow, which produce a monoclonal spike on serum protein electrophoresis. The clinical presentation of weakness, bone pain, and recurrent infections is typical of multiple myeloma. Anemia can result from bone marrow infiltration by the abnormal plasma cells, hypercalcemia is due to bone destruction and release of calcium, renal insufficiency can result from hypercalcemia and protein deposition in the kidneys, and the monoclonal spike in serum protein electrophoresis indicates the presence of a monoclonal protein. Waldenström macroglobulinemia, Hodgkin lymphoma, and chronic lymphocytic leukemia do not typically present with the classic tetrad of findings seen in multiple myeloma.
A patient presents with hoarseness, dysphonia, and occasional throat pain. Direct laryngoscopy reveals vocal cord nodules. Which of the following interventions is most appropriate for managing this condition?
- A. Vocal cord polypectomy
- B. Vocal cord injection with corticosteroids
- C. Voice therapy and vocal hygiene education
- D. Partial laryngectomy
Correct Answer: C
Rationale: Vocal cord nodules are benign growths on the vocal cords, typically caused by vocal abuse or misuse. The most appropriate intervention for managing vocal cord nodules is voice therapy and vocal hygiene education. Voice therapy aims to correct vocal habits and techniques that contribute to the formation of nodules, while vocal hygiene education focuses on maintaining vocal health through proper hydration, rest, and avoiding behaviors that strain the vocal cords. These interventions have been shown to be effective in reducing and eliminating vocal cord nodules without the need for surgical intervention. Surgery, such as vocal cord polypectomy or injection with corticosteroids, is typically reserved for cases that do not respond to conservative management or if there are significant complications. Partial laryngectomy is a more extensive surgical procedure that is not typically indicated for vocal cord nodules.