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The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.
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When can a donor and recipient of blood be considered compatible?
- A. If there is no change in the blood color when both samples are mixed in the laboratory
- B. If there are blood clots when both samples are mixed in the laboratory
- C. If there is no clumping or hemolysis when both samples are mixed in the laboratory
- D. If a blood drop does not sink when dropped in water after both samples are mixed in the laboratory
Correct Answer: C
Rationale: The correct answer is C because compatibility between blood donor and recipient is determined by the absence of clumping or hemolysis when both samples are mixed. Clumping indicates an incompatible blood type reaction, leading to potential harm. Blood clots (option B) are not indicative of compatibility but rather a sign of coagulation issues. Blood color change (option A) and blood drop sinking in water (option D) are not reliable indicators of blood compatibility. In summary, option C is correct as it directly assesses for the absence of a harmful reaction, while the other choices do not accurately determine blood compatibility.
An African client has been diagnosed with Osteomyelitis. The nurse expects to assess which of the following?
- A. pale, cool, tender skin at site
- B. decreased white blood cell count
- C. positive wound cultures
- D. decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: The correct answer is C: positive wound cultures. Osteomyelitis is an infection of the bone that is typically diagnosed through wound cultures. This assessment helps to identify the causative organism and guide appropriate treatment. Choices A and D are not typical findings in osteomyelitis. Choice A describes symptoms of poor circulation which are not specific to osteomyelitis. Choice B, decreased white blood cell count, is typically not seen in the presence of an infection like osteomyelitis.
Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:
- A. Kaposi's Sarcoma
- B. Pneumonia Carnii
- C. Filterable Virus
- D. Staphylococcus bacteria
Correct Answer: B
Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.
Which action will the nurse take after the plan of care for a patient is developed?
- A. Place the original copy in the chart, so it cannot be tampered with or revised.
- B. Communicate the plan to all health care professionals involved in the patient’s care.
- C. File the plan of care in the administration office for legal examination. NursingStoreRN
- D. Send the plan of care to quality assurance for review.
Correct Answer: B
Rationale: The correct answer is B because after developing a plan of care, the nurse must communicate it to all healthcare professionals involved in the patient's care to ensure everyone is aware of the plan and can collaborate effectively. This promotes continuity of care and prevents errors.
Choice A is incorrect because the plan of care should not be placed in the chart to avoid tampering; it should be easily accessible for updates. Choice C is incorrect as filing in the administration office is unnecessary for routine care. Choice D is incorrect as sending the plan to quality assurance is not the immediate next step after developing the plan.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
- A. Self-care deficient: Bathing/hygiene
- B. Dysfunctional grieving
- C. Ineffective cerebral tissue perfusion
- D. Risk for injury
Correct Answer: C
Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration.
Summary:
A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications.
B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue.
D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.