Nokea
The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain?
- A. 10-mL Luer-Lok syringe
- B. Asepto syringe
- C. Sterile gloves
- D. Double gloves
Correct Answer: A
Rationale: The correct answer is A: 10-mL Luer-Lok syringe. The nurse should use this syringe to obtain a gastric aspirate for pH testing because it allows for accurate measurement of the aspirate volume. Asepto syringe (B) is not suitable for this purpose as it is not designed for accurate measurement. Sterile gloves (C) and double gloves (D) are not equipment used specifically for obtaining gastric aspirate for pH testing. Sterile gloves are used for infection control, and double gloves are used for additional protection during procedures.
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A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location precludes the use of enteral feeding. What intervention should the nurse identify as best meeting this patients nutritional needs?
- A. Administration of parenteral feeds via a peripheral IV
- B. TPN administered via a peripherally inserted central catheter
- C. Insertion of an NG tube for administration of feeds
- D. Maintaining NPO status and IV hydration until treatment completion
Correct Answer: B
Rationale: The correct answer is B: TPN administered via a peripherally inserted central catheter. TPN provides comprehensive nutrition intravenously, bypassing the GI tract, which is important for patients unable to tolerate oral intake. A peripherally inserted central catheter allows for long-term TPN administration.
A: Administration of parenteral feeds via a peripheral IV is not ideal for long-term nutrition as it may not provide complete nutrition.
C: Insertion of an NG tube may not be feasible due to the tumor location and the patient's inability to tolerate oral intake.
D: Maintaining NPO status and IV hydration alone may lead to malnutrition over time as it does not provide adequate nutrition.
A nurse knows of several patients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which patient?
- A. A patient who has previously been treated for tuberculosis
- B. A pregnant woman at 30 weeks gestation
- C. A patient who is on estrogen-replacement therapy
- D. A patient with a severe allergy to eggs
Correct Answer: B
Rationale: The correct answer is B. Antihistamines are generally considered safe during pregnancy, but it is recommended to avoid unnecessary medications, especially in the third trimester. Antihistamines should be used cautiously in pregnant women due to potential effects on the fetus. Choice A is incorrect because previous treatment for tuberculosis does not contraindicate the use of antihistamines. Choice C is incorrect as estrogen-replacement therapy does not interact significantly with antihistamines. Choice D is incorrect as a severe allergy to eggs does not directly contraindicate the use of antihistamines.
A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
- A. Modified radical mastectomies are very hard on a patient, both physically and emotionally and they really arent necessary anymore.
- B. According to current guidelines, having a modified radical mastectomy is no longer seen as beneficial.
- C. Modified radical mastectomies have a poor survival rate because of the risk of cancer recurrence.
- D. According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
Correct Answer: D
Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer.
2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy.
3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer.
4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal.
5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.
The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an appropriate nursing diagnosis is anxiety related to lack of control over the health circumstances. In establishing this plan of care for the patient, the nurse should include what intervention?
- A. The patient will receive antianxiety medications every 4 hours.
- B. The patients family will be instructed on planning the patients care.
- C. The patient will be encouraged to verbalize concerns related to the disease and its treatment.
- D. The patient will begin intensive therapy with the goal of distraction.
Correct Answer: C
Rationale: The correct answer is C because encouraging the patient to verbalize concerns can help alleviate anxiety by allowing the patient to express emotions and fears. This intervention promotes emotional expression and provides an outlet for the patient to discuss their worries. This can lead to increased understanding and support.
Incorrect answers:
A: Administering antianxiety medications does not address the underlying cause of anxiety and may lead to dependency.
B: Instructing the family on planning care does not directly address the patient's anxiety.
D: Distracting the patient may provide temporary relief but does not address the root cause of anxiety related to lack of control over health circumstances.
A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
- A. Ineffective Airway Clearance
- B. Impaired Oral Mucous Membranes
- C. Imbalanced Nutrition: Less than Body Requirements
- D. Activity Intolerance
Correct Answer: A
Rationale: The correct answer is A: Ineffective Airway Clearance. In a patient with AIDS and PCP, maintaining clear airways is crucial to prevent respiratory distress and hypoxia. Pneumocystis pneumonia can cause thick secretions and mucus plugging, leading to difficulty breathing. Ensuring effective airway clearance is a priority to optimize oxygenation and prevent respiratory complications. Impaired oral mucous membranes (B) and imbalanced nutrition (C) are important considerations but not as immediate as airway clearance. Activity intolerance (D) may be a concern for the patient but ensuring adequate oxygenation takes precedence.