Nokea
The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
- A. Instructing the patient about this diagnostic test
- B. Writing the order for this test
- C. Giving the patient breakfast
- D. All of the above
Correct Answer: A
Rationale: The nurse's responsibility in this scenario is to instruct the patient about the diagnostic test ordered by the physician. This includes explaining the purpose of the test, any necessary preparations, and what to expect. The nurse is not responsible for writing the order, as this is the physician's role. Additionally, providing breakfast is not directly related to the platelet count test. Therefore, the correct answer is A, which aligns with the nurse's role in educating and supporting the patient regarding the test.
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A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct Answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?
- A. Discourage them from deciding until their grief has eased
- B. Listen to their concerns and answer their questions truthfully
- C. Urge them to immediately sign the consent form
- D. Inform them that the body will not be available for a wake or funeral
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping, and muscle weakness. These symptoms probably indicate that the patient is experiencing:
- A. Hypokalemia
- B. Hyperkalemia
- C. Anorexia
- D. Dysphagia
Correct Answer: A
Rationale: The symptoms of fatigue, muscle cramping, and muscle weakness in a patient after starting furosemide therapy are indicative of hypokalemia. Furosemide is a loop diuretic that can lead to potassium depletion, causing hypokalemia. Hypokalemia can manifest with muscle weakness, cramps, and fatigue due to alterations in neuromuscular function and decreased ATP production.
What is the primary purpose of a platelet count?
- A. Assessing clot formation potential
- B. Assessing bleeding risk
- C. Detecting antigen-antibody response
- D. Identifying cardiac enzymes presence
Correct Answer: B
Rationale: A platelet count is primarily used to assess the risk of bleeding. Platelets play a crucial role in blood clotting, so a low platelet count can lead to an increased risk of bleeding. Monitoring platelet levels helps healthcare providers evaluate a patient's ability to form clots and manage bleeding.
A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8°F (37.7°C). This temperature reading probably indicates:
- A. Infection
- B. Hypothermia
- C. Anxiety
- D. Dehydration
Correct Answer: D
Rationale: A patient being kept off food and fluids before surgery can lead to dehydration. Dehydration can cause a slight increase in body temperature, which could explain the elevated oral temperature reading of 99.8°F (37.7°C) in this scenario. Infections are more likely to cause higher fevers, hypothermia would present with a lower temperature, and anxiety typically does not directly affect body temperature in this manner.