Nokea
The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?
- A. Run lipids for no longer than 24 hours.
- B. Take down a running bag of TPN after 36 hours.
- C. Clean injection port with alcohol 5 seconds before and after use.
- D. Wear a sterile mask when changing the central venous catheter dressing.
Correct Answer: D
Rationale: When caring for a patient receiving total parenteral nutrition (TPN), it is crucial to maintain strict aseptic technique to prevent infection. Wearing a sterile mask when changing the central venous catheter dressing helps to reduce the risk of introducing pathogens into the catheter site, which can lead to serious bloodstream infections. It is essential to use sterile gloves, a sterile mask, and to assess the insertion site for any signs or symptoms of infection during central venous catheter dressing changes. Additionally, to prevent infection, TPN infusion tubing should be changed every 24 hours, and no single container of TPN should be hung for longer than 24 hours, with lipids not running for longer than 12 hours.
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A nurse is evaluating a nursing assistive personnel’s(NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene?
- A. Emptying the drainage bag when half full
- B. Kinking the catheter tubing to obtain a urine specimen
- C. Placing the drainage bag on the side rail of the patient’s bed
- D. Securing the catheter tubing to the patient’s thigh
Correct Answer: C
Rationale: Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the other actions are correct procedures and do not require immediate follow-up. The drainage bag should be emptied when it is half full to prevent tension and pulling on the catheter, which could result in trauma to the urethra and increase the risk for urinary tract infections. Urine specimens are traditionally obtained by temporarily kinking the tubing, while securing the catheter tubing to the patient’s thigh prevents catheter dislodgment and tissue injury.
A 25-year-old patient diagnosed with invasive cervical cancer expresses a desire to have children. What procedure might the physician offer as treatment?
- A. Radical hysterectomy
- B. Radical culposcopy
- C. Radical trabeculectomy
- D. Radical trachelectomy
Correct Answer: D
Rationale: Radical trachelectomy is a surgical procedure that involves the removal of the cervix while preserving the uterus. This procedure is often offered to young women diagnosed with early-stage cervical cancer who wish to preserve their fertility and have children in the future. By removing the cervix and part of the upper vagina, while leaving the uterus intact, radical trachelectomy offers these patients a chance at preserving their ability to conceive and carry a pregnancy to term. It is a fertility-sparing option in the management of cervical cancer, particularly in younger patients like the 25-year-old mentioned in the question.
The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid?
- A. Washing his face
- B. Exposing his skin to sunlight
- C. Using artificial tears
- D. Drinking large amounts of fluids
Correct Answer: A
Rationale: Trigeminal neuralgia is a condition characterized by severe facial pain due to irritation or damage to the trigeminal nerve. Factors such as touching or lightly brushing the face, chewing, speaking, or even encountering a breeze can trigger an attack. Therefore, activities like washing the face that involve touching or stimulating the trigeminal nerve can precipitate an attack in patients with trigeminal neuralgia. It is important for patients to be aware of these triggers to help manage and prevent episodes of pain.
A patient is in the primary infection stage of HIV. What is true of this patients current health status?
- A. The patients HIV antibodies are successfully, but temporarily, killing the virus.
- B. The patient is infected with HIV but lacks HIV-specific antibodies.
- C. The patients risk for opportunistic infections is at its peak.
- D. The patient may or may not develop long-standing HIV infection.
Correct Answer: B
Rationale: During the primary infection stage of HIV, the patient is newly infected with the virus. At this stage, the patient's immune system has not yet produced HIV-specific antibodies, making it difficult to detect HIV infection using standard antibody tests. Instead, the virus can be detected by testing for the presence of HIV RNA or p24 antigen. The primary infection stage is characterized by a high level of viral replication and rapid spread of the virus throughout the body. In this early stage, the patient may experience flu-like symptoms such as fever, sore throat, muscle aches, and swollen lymph nodes. The absence of HIV-specific antibodies means that the patient is highly infectious and can easily transmit the virus to others. As the infection progresses, the patient will eventually develop HIV-specific antibodies, which can be detected through antibody tests.
A patient expresses concerns over having blackstool. The fecal occult test is negative. Which response by the nurse is mostappropriate?
- A. “This is probably a false negative; we should rerun the test.”
- B. “You should schedule a colonoscopy as soon as possible.”
- C. “Are you under a lot of stress?”
- D. “Do you take iron supplements?”
Correct Answer: D
Rationale: Black or tarry stools can be caused by certain medications and supplements, such as iron supplements. Since the fecal occult test is negative, it indicates that bleeding is not occurring. Therefore, in this situation, it is important to consider factors that can affect the color of stool, including iron supplementation. Addressing this question can help determine the cause of the black stool and provide appropriate guidance or reassurance to the patient. This response shows a comprehensive understanding of potential causes and demonstrates a thoughtful approach in addressing the patient's concern.