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times. II before removing from the shelf. III before measuring actual dose. IV before opening a unit dose-container.
- A. II & III
- B. I, II & III
- C. I & II
- D. I, II, III, & IV
Correct Answer: D
Rationale: It is important to check the medication label against the medication order before administering any medication to ensure accuracy.
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A patient presents with grouped vesicles on an erythematous base, affecting the lips and perioral region. The patient reports a history of similar episodes triggered by sunlight exposure and stress. Which of the following conditions is most likely responsible for this presentation?
- A. Herpes simplex labialis (cold sores)
- B. Perioral dermatitis
- C. Angular cheilitis
- D. Allergic contact dermatitis
Correct Answer: A
Rationale: The patient's presentation with grouped vesicles on an erythematous base affecting the lips and perioral region, triggered by sunlight exposure and stress, is classic for herpes simplex labialis, commonly known as cold sores. Herpes simplex virus type 1 (HSV-1) is responsible for cold sores and is highly contagious. Recurrent episodes can be triggered by factors like UV exposure, stress, illness, and hormonal changes. Symptoms typically start with tingling or burning sensations before progressing to grouped vesicles that rupture, forming crusts. Treatment may involve antiviral medications to reduce the severity and duration of symptoms. Perioral dermatitis typically presents with papules and pustules around the mouth, while angular cheilitis involves fissures and inflammation at the corners of the mouth. Allergic contact dermatitis would present with erythema, pruritus, and possibly vesicles in
During the first contact of the patient with the nurse, the latter should demonstrate the following behavior, which the EXCEPTION of _______.
- A. Caring
- B. Encouraging
- C. Comforting
- D. Compelling
Correct Answer: D
Rationale: During the first contact with a patient, a nurse should demonstrate caring, encouraging, and comforting behaviors. These qualities help create a positive and supportive environment for the patient. However, compelling behavior, which implies forcing or pressuring someone to do something, is not appropriate during the initial interaction with a patient. It is essential for the nurse to build trust and rapport with the patient, and compelling behavior can be counterproductive to establishing a nurturing relationship. Thus, compelling is the exception among the given choices for the nurse's behavior during the first contact with a patient.
Patient Josephine was referred to the physician, routine blood examinations were taken. After reviewing the serum electrolyte. levels an order of isotonic intravenous (IV) infusion was prescribed. Which IV solution should the nurse prepare?
- A. 5 percent dextrose in water
- B. 0.45 percent sodium chloride solution
- C. 10 percent dextrose in water
- D. 3 percent sodium chloride solution
Correct Answer: B
Rationale: The order for isotonic intravenous (IV) infusion indicates that the IV solution should have an osmolarity similar to that of blood serum, which is approximately 0.9 percent sodium chloride solution (normal saline). In the given choices, the closest option to isotonic solution is the 0.45 percent sodium chloride solution. This solution is hypotonic compared to blood serum, making it a suitable choice for isotonic IV infusion to prevent fluid shifts and maintain electrolyte balance in the patient. The other options, such as 5 percent dextrose in water (hypotonic), 10 percent dextrose in water (hypertonic), and 3 percent sodium chloride solution (hypertonic), do not match the requirement for an isotonic IV solution in this case.
A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?
- A. Lying in bed on the affected side
- B. Lying in bed on the unaffected side
- C. Sims position with the head of the bed flat
- D. Prone with the head turned to the side and supported by a pillow
Correct Answer: B
Rationale: The client should be assisted to lie in bed on the unaffected side for a thoracentesis procedure. This position allows for better access to the pleural space for the insertion of a needle to aspirate the fluid or air. Gravity helps to separate the fluid or air, making it closer to the chest wall for easier removal. Additionally, this position reduces the risk of injury to the lung or other structures, as the needle is directed away from these vital structures. Lying on the unaffected side also helps in preventing potential complications and ensures the safety and effectiveness of the procedure.
A patient expresses fear of needles before a scheduled blood draw. What is the nurse's best approach to address this fear?
- A. Dismiss the patient's fear and proceed with the blood draw.
- B. Provide the patient with information about relaxation techniques and distraction methods.
- C. Ignore the patient's fear and proceed with the blood draw quickly.
- D. Tell the patient that fear of needles is irrational and unfounded.
Correct Answer: B
Rationale: The nurse's best approach to address the patient's fear of needles before a blood draw is to provide the patient with information about relaxation techniques and distraction methods (Option B). Dismissing the patient's fear (Option A), ignoring the fear and proceeding quickly (Option C), or telling the patient that the fear is irrational and unfounded (Option D) would not be helpful and could potentially escalate the patient's anxiety. Providing information on relaxation techniques such as deep breathing or visualization, as well as distraction methods like listening to music or engaging in conversation, can help the patient feel more comfortable and reduce their fear and anxiety during the blood draw procedure. It is important for the nurse to acknowledge and address the patient's concerns in a supportive and empathetic manner to build trust and ensure a successful blood draw experience.