Nokea
The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses most appropriate action?
- A. Assess the patient for additional signs and symptoms of Kaposis sarcoma.
- B. Review the patients most recent viral load and CD4+ count.
- C. Place the patient on respiratory isolation and inform the physician.
- D. Perform oral suctioning to reduce the patients risk for aspiration.
Correct Answer: C
Rationale: The correct answer is C: Place the patient on respiratory isolation and inform the physician. This is the most appropriate action because the patient is exhibiting symptoms that could be indicative of a potentially infectious respiratory condition, such as tuberculosis or pneumonia. Placing the patient on respiratory isolation helps prevent the spread of infection to others and protects healthcare workers. Informing the physician promptly allows for further evaluation and appropriate treatment.
Choice A is incorrect as Kaposi's sarcoma typically presents with skin lesions rather than respiratory symptoms. Choice B is incorrect as reviewing viral load and CD4+ count would not address the immediate concern of respiratory symptoms. Choice D is incorrect as oral suctioning is not the appropriate intervention for night sweats and coughing up blood.
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A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patients history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic?
- A. A referral for a mammogram
- B. Instructions about breast self-examination (BSE)
- C. A referral to a surgeon
- D. A referral to a support group
Correct Answer: A
Rationale: The correct answer is A: A referral for a mammogram. Given the family history of breast cancer in the patient's father, the nurse should recommend a mammogram as a preventive measure due to increased risk. Mammograms are effective in detecting breast cancer early, especially in individuals with a family history. This can help in early diagnosis and timely intervention if needed.
B: Instructions about breast self-examination (BSE) can be helpful, but in this case, a mammogram is a more definitive screening tool for high-risk individuals.
C: A referral to a surgeon is not necessary at this point as the patient does not exhibit any symptoms of breast cancer.
D: Referral to a support group may be beneficial for emotional support, but the priority should be on proactive screening measures like a mammogram.
A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defined nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment?
- A. Lumpectomy and radiation
- B. Partial mastectomy and radiation
- C. Partial mastectomy and chemotherapy
- D. Total mastectomy and chemotherapy
Correct Answer: A
Rationale: The correct answer is A: Lumpectomy and radiation. For a small, well-defined nodule in the breast, lumpectomy (removal of the lump) followed by radiation therapy is usually the treatment of choice for early-stage breast cancer. This approach aims to preserve the breast while ensuring effective treatment. Partial mastectomy (B) involves removing a larger portion of the breast tissue and is not typically necessary for a small, well-defined nodule. Chemotherapy (C) is generally used for more advanced stages of breast cancer or when the cancer has spread beyond the breast. Total mastectomy (D) is considered when the cancer is more extensive or in cases where lumpectomy is not feasible.
A placenta previa when the placental edge just reaches the internal os is called
- A. total.
- B. partial.
- C. low-lying.
- D. marginal.
Correct Answer: D
Rationale: The correct answer is D, marginal. Placenta previa is classified based on the proximity of the placental edge to the internal os. In a marginal placenta previa, the placental edge just reaches the internal os. This is a crucial distinction as it poses a higher risk for bleeding during labor. Total placenta previa covers the entire internal os, partial placenta previa partially covers the internal os, and low-lying placenta is when the placenta is close to but not covering the internal os. Therefore, D is correct as it accurately describes the specific position of the placenta edge in relation to the internal os in cases of marginal placenta previa.
A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patients family and friends?
- A. Your family should likely gather at the bedside in case theres a negative outcome.
- B. Make sure she doesnt eat any food in the 24 hours before the procedure.
- C. Wear a hospital gown when you go into the patients room.
- D. Do not visit if youve had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: Do not visit if you've had a recent infection. This is crucial to prevent the transmission of infections to the patient, who will have a compromised immune system post-HSCT. Family and friends with recent infections can pose a serious risk to the patient's health.
Choice A is incorrect because it instills fear and negativity in the family without providing any tangible benefits.
Choice B is incorrect as fasting is not typically required before a HSCT and can be harmful to the patient's nutritional status.
Choice C is incorrect as wearing a hospital gown is generally not necessary for visitors, unless specified by the healthcare team for infection control purposes.
A nurse wants to find the daily weights of apatient. Which form will the nurse use?
- A. Database
- B. Progress notes
- C. Patient care summary
- D. Graphic record and flow sheet
Correct Answer: D
Rationale: The correct answer is D: Graphic record and flow sheet. The nurse will use a graphic record and flow sheet to document the patient's daily weights. This form allows for easy tracking and visualization of weight trends over time. Database (A) is used for storing large amounts of data but not ideal for daily weight tracking. Progress notes (B) are for narrative descriptions of patient care, not specific for daily weights. Patient care summary (C) provides an overview of the patient's care plan, not detailed daily weights.