Nokea
The patient develops a low-grade fever 18 hours post-operatively and has diminished breath sounds. Which of the following actions is most appropriate for the nurse to take to prevent complications? i.Administer antibiotics iv.Decrease fluid intake ii.Encourage coughing and deepbreathing v.Ambulate patient as ordered iii.Administer acetaminophen (Tylenol)
- A. 2and 5
- B. All of the above
- C. 1, 3 and 4
- D. All except 2
Correct Answer: A
Rationale: The correct answer is A: 2 and 5. Diminished breath sounds indicate possible atelectasis or pneumonia post-operatively, making coughing and deep breathing (2) and ambulation (5) crucial to prevent complications. Decreasing fluid intake (iv) can lead to dehydration, worsening the situation. Administering antibiotics (i) without further assessment may not be necessary at this point. Acetaminophen (iii) can help with fever but does not address the underlying respiratory issue.
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During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi’s sarcoma
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. In AIDS patients, Kaposi’s sarcoma is a common cancer caused by human herpesvirus 8. It presents as purple or brown skin lesions. Squamous cell carcinoma (A), leukemia (B), and multiple myeloma (C) are not commonly associated with AIDS. Squamous cell carcinoma is linked to sun exposure, leukemia originates in the bone marrow, and multiple myeloma is a cancer of plasma cells. Therefore, the correct answer is D due to its strong association with AIDS.
A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
- A. The patient will ambulate in hallways.
- B. The nurse will monitor the patient’s heart rhythm continuously this shift. The patient will feed self at all mealtimes today without reports of shortness of
- C. breath. The nurse will administer pain medication every 4 hours to keep the patient free from
- D. discomfort.
Correct Answer: B
Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.
A male client who is HIV positive is admitted to the hospital with a diagnosis of Pneumocystis carinii pneumonia. His live-in partner has accompanied him. During the history interview, the nurse is aware of feeling a negative attitude about the client’s lifestyle, what action is most appropriate?
- A. Share these feelings with the client
- B. Discuss the negative feelings with the
- C. Develop a written interview form charge nurse
- D. Avoid eye contact with the client
Correct Answer: B
Rationale: The correct answer is B: Discuss the negative feelings with the client. This is the most appropriate action as it allows the nurse to address and manage their own biases and attitudes towards the client in a professional and constructive manner. By acknowledging and discussing these feelings with the client, the nurse can work towards providing non-judgmental care and fostering a therapeutic relationship.
A: Sharing these feelings with the client is not appropriate as it can harm the nurse-client relationship and potentially lead to discrimination.
C: Developing a written interview form is not addressing the immediate issue of the nurse's negative attitude towards the client.
D: Avoiding eye contact with the client is unprofessional and does not address the underlying issue of the nurse's negative feelings.
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. Mobile mass that is soft and easily
- C. Non-mobile mass with irregular edges delineated
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges delineated. This finding strongly suggests cancer as non-mobile masses with irregular edges are characteristic of malignant tumors. Cancerous lumps tend to be fixed in place due to involvement of surrounding tissues. Irregular edges indicate potential invasive growth. Choices A and B describe characteristics more commonly associated with benign masses. Eversion of the nipple is concerning for cancer but not specific enough to strongly suggest malignancy. Choice D indicates absence of lymph node involvement, which is not directly related to the characteristics of the breast lump.
What should be included in the teaching plan to young adults about the spread of AIDS?
- A. Heterosexual transmission of HIV is on the rise
- B. The increase of HIV in children is primarily attributed to the rise in sexual abuse
- C. Herpes zoster is a form of the HIV virus
- D. Transmission of HIV by IV drug users is prominent even when sterile equipment is used
Correct Answer: A
Rationale: The correct answer is A because educating young adults about the rise in heterosexual transmission of HIV is crucial to prevent the spread of AIDS. This information helps them understand the importance of safe sex practices and awareness of risks. Choice B is incorrect as HIV transmission in children is not primarily due to sexual abuse. Choice C is also incorrect as herpes zoster is not a form of the HIV virus. Choice D is incorrect as transmission by IV drug users is not prominent with sterile equipment use. Focusing on the rise in heterosexual transmission is key in teaching young adults about AIDS prevention.