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What are the signs of organ rejection a nurse should closely monitor for when caring for a client after heart transplantation? Choose all that apply
- A. Low white blood cell count
- B. Dyspnea
- C. ECG changes
- D. Fever
Correct Answer: A
Rationale: When caring for a client after heart transplantation, the signs of organ rejection that a nurse should closely monitor for include low white blood cell count and dyspnea.
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Nursing intervention during the lumbar puncture procedure includes:
- A. Monitoring Mrs. GC's color, pulse and respiration
- B. Labeling all laboratory specimens in numerical order
- C. Positioning Mrs. GC on her side with knees drawn up to her chest
- D. All of the above
Correct Answer: C
Rationale: During a lumbar puncture procedure, it is important to position the patient correctly to facilitate the procedure and minimize the risk of complications. Placing the patient on their side with their knees drawn up to their chest helps open up the spaces in the lower spine, making it easier for the healthcare provider to access the appropriate area for the procedure. This position also helps to minimize the risk of post-procedure complications such as spinal headaches. Monitoring the patient's vital signs is important but does not specifically relate to the nursing intervention during the lumbar puncture procedure. Labeling laboratory specimens in numerical order is also a routine task but not directly related to the procedure itself. Thus, the correct intervention during the lumbar puncture procedure is positioning the patient on their side with knees drawn up to the chest.
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
- A. "Take zidovudine with meals."
- B. "Take zidovudine on an empty stomach."
- C. "Take zidovudine every 4 hours around the clock."
- D. "Take over-the-counter(OTC) drugs to treat minor adverse reactions."
Correct Answer: C
Rationale: Zidovudine (AZT) is an antiretroviral drug used to treat HIV infection, including in AIDS patients. It is important to follow the prescribed dosing schedule to maintain consistent drug levels in the body and effectively control the HIV virus. Taking zidovudine every 4 hours around the clock helps ensure the medication's therapeutic effects are maintained throughout the day. It is crucial for the client to adhere to the prescribed dosing regimen to prevent the development of drug resistance and to achieve the best treatment outcomes. Taking zidovudine with meals, on an empty stomach, or taking over-the-counter drugs for minor adverse reactions are not the correct instructions related to the dosing schedule of zidovudine.
Which is instituted for the therapeutic management of minimal change nephrotic syndrome?
- A. Corticosteroids
- B. Antihypertensive agents
- C. Long-term diuretics
- D. Increased fluids to promote diuresis
Correct Answer: A
Rationale: Corticosteroids are the mainstay of therapy for minimal change nephrotic syndrome. Minimal change disease is the most common cause of nephrotic syndrome in children, and corticosteroids are highly effective in inducing remission in these patients. They work by reducing inflammation and decreasing the permeability of the glomerular filtration barrier in the kidneys, thereby reducing proteinuria. Antihypertensive agents are used to control blood pressure in patients with renal involvement, and long-term diuretics are not typically recommended in nephrotic syndrome due to the risk of worsening kidney function. Increased fluids to promote diuresis are also not indicated as the primary treatment for minimal change nephrotic syndrome.
The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine is believed to be the drug involved. Data collection should include what information?
- A. Mode of administration
- B. Drug's actual content
- C. Function the drug plays in the adolescent's life
- D. Adolescent's level of interest in rehabilitation
Correct Answer: A
Rationale: When caring for an adolescent with acute drug toxicity, it is important to gather information on the mode of administration of the drug to understand how it was taken into the body. This information can help the healthcare team determine the extent of drug exposure, potential complications, and appropriate treatment strategies. The mode of administration can include ingestion, inhalation, injection, or other routes, and each method may have different implications for the patient's condition. Understanding how the drug was administered is crucial in managing the adolescent's care effectively.
A nurse manager at a home-care agency is planning a continuing education program for the home-care staff nurses. Which type of continuing education program should the nurse manager plan?
- A. On-line training modules
- B. A structured written teaching module each nurse completes individually
- C. A workshop training day, with a professional speaker, where nurses can interact with each other
- D. One-on-one continuing education training with each nurse
Correct Answer: C
Rationale: A workshop training day with a professional speaker where nurses can interact with each other would be the most beneficial type of continuing education program for home-care staff nurses. This type of program allows for interactive learning and the opportunity for nurses to engage in discussions, ask questions, and share experiences with each other. It promotes a collaborative learning environment, fosters teamwork, and enhances communication among the staff. Additionally, bringing in a professional speaker can provide valuable insights and expertise on relevant topics, further enriching the education experience for the nurses. Overall, a workshop training day would be a more engaging and effective approach to continuing education for the home-care staff nurses compared to the other options listed.