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The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine is believed to be the drug involved. Data collection should include what information?
- A. Mode of administration
- B. Drug's actual content
- C. Function the drug plays in the adolescent's life
- D. Adolescent's level of interest in rehabilitation
Correct Answer: A
Rationale: When caring for an adolescent with acute drug toxicity, it is important to gather information on the mode of administration of the drug to understand how it was taken into the body. This information can help the healthcare team determine the extent of drug exposure, potential complications, and appropriate treatment strategies. The mode of administration can include ingestion, inhalation, injection, or other routes, and each method may have different implications for the patient's condition. Understanding how the drug was administered is crucial in managing the adolescent's care effectively.
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During starvation, the body slows metabolic processes and growth to minimize the need for nutrients. With the rapid reinstitution of feeding after starvation refeeding syndrome may occur. Of the following, the major changes that may occur with refeeding syndrome typically affect
- A. electrolytes
- B. serum proteins
- C. hormones
- D. liver enzymes
Correct Answer: A
Rationale: Refeeding syndrome primarily affects electrolytes, particularly phosphorus, potassium, and magnesium, which can become dangerously depleted due to rapid shifts in metabolism.
Which is the leading cause of death in infants younger than 1 year?
- A. Congenital anomalies
- B. Sudden infant death syndrome
- C. Respiratory distress syndrome
- D. Bacterial sepsis of the newborn
Correct Answer: A
Rationale: Congenital anomalies are the leading cause of death in infants younger than 1 year. These anomalies are conditions that a baby is born with, either due to genetic factors or other factors during fetal development. They can affect various parts of the body, such as the heart, brain, or other organs. Congenital anomalies can be severe and life-threatening, leading to infant mortality. Sudden Infant Death Syndrome (SIDS) is also a significant cause of infant deaths, but congenital anomalies are more commonly cited as the leading cause of death in this age group.
Nursing intervention during the lumbar puncture procedure includes:
- A. Monitoring Mrs. GC's color, pulse and respiration
- B. Labeling all laboratory specimens in numerical order
- C. Positioning Mrs. GC on her side with knees drawn up to her chest
- D. All of the above
Correct Answer: C
Rationale: During a lumbar puncture procedure, it is important to position the patient correctly to facilitate the procedure and minimize the risk of complications. Placing the patient on their side with their knees drawn up to their chest helps open up the spaces in the lower spine, making it easier for the healthcare provider to access the appropriate area for the procedure. This position also helps to minimize the risk of post-procedure complications such as spinal headaches. Monitoring the patient's vital signs is important but does not specifically relate to the nursing intervention during the lumbar puncture procedure. Labeling laboratory specimens in numerical order is also a routine task but not directly related to the procedure itself. Thus, the correct intervention during the lumbar puncture procedure is positioning the patient on their side with knees drawn up to the chest.
The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?
- A. Universal blood and body fluid precautions
- B. Body systems isolation
- C. Laminar flow room during active infection
- D. Needle and syringe precautions
Correct Answer: A
Rationale: The Centers for Disease Control and Prevention (CDC) recommend universal blood and body fluid precautions for preventing the spread of the HIV virus. These precautions are designed to protect healthcare workers and patients from exposure to bloodborne pathogens. Universal precautions involve treating all blood and body fluids from all individuals as potentially infectious. This includes using personal protective equipment (such as gloves, gowns, and masks), proper handling and disposal of needles and other sharps, and following appropriate infection control practices. By implementing universal precautions, healthcare providers can minimize the risk of transmission of HIV and other bloodborne pathogens.
A nurse manager at a home-care agency is planning a continuing education program for the home-care staff nurses. Which type of continuing education program should the nurse manager plan?
- A. On-line training modules
- B. A structured written teaching module each nurse completes individually
- C. A workshop training day, with a professional speaker, where nurses can interact with each other
- D. One-on-one continuing education training with each nurse
Correct Answer: C
Rationale: A workshop training day with a professional speaker where nurses can interact with each other would be the most beneficial type of continuing education program for home-care staff nurses. This type of program allows for interactive learning and the opportunity for nurses to engage in discussions, ask questions, and share experiences with each other. It promotes a collaborative learning environment, fosters teamwork, and enhances communication among the staff. Additionally, bringing in a professional speaker can provide valuable insights and expertise on relevant topics, further enriching the education experience for the nurses. Overall, a workshop training day would be a more engaging and effective approach to continuing education for the home-care staff nurses compared to the other options listed.