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What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The nurse should instruct the patient taking propranolol (Inderal) for hypertension to not stop the medication abruptly. Suddenly stopping propranolol can lead to rebound hypertension and potentially dangerous side effects. It is important for the patient to gradually taper off the medication under the guidance of a healthcare provider to avoid complications. Therefore, advising the patient not to stop the medication abruptly is a crucial instruction to ensure their safety and well-being.
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An elderly client develops severe bone marrow depression from chemotheraphy for cancer of the prostate. The nurse should;
- A. Monitor Intake and output of fluids
- B. Increase dally intake of fluids
- C. Use a soft toothbrush for oral hygiene HEMATOPOIETIC AND LYMPHATIC SYSTEMS
Correct Answer: A
Rationale: Monitoring intake and output of fluids is essential for an elderly client who develops severe bone marrow depression from chemotherapy for prostate cancer. Bone marrow depression can result in decreased production of blood cells, including red blood cells, white blood cells, and platelets. Monitoring intake and output of fluids helps assess hydration status and kidney function. Decreased fluid intake or output may indicate kidney damage or dehydration, which are common concerns in clients with bone marrow depression. Therefore, it is crucial for the nurse to monitor the client's fluid balance closely to ensure optimal functioning of the kidneys and prevent complications related to bone marrow suppression.
When taking the blood pressure of a client who has AIDS the nurse must;
- A. Wear a mask and gown
- B. Use barrier techniques
- C. Wash the hands thoroughly
Correct Answer: B
Rationale: When taking the blood pressure of a client with AIDS, it is important for the nurse to use barrier techniques to prevent the potential transmission of infection. This includes wearing gloves to protect against exposure to blood or other bodily fluids, using disposable blood pressure cuffs and stethoscopes, and ensuring proper hand hygiene before and after the procedure. Barrier techniques help minimize the risk of cross-contamination and protect both the healthcare provider and the client from potential infections.
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
- A. A-positive blood to an A-negative client
- B. O-positive blood to an A-positive client
- C. O-negative blood to an O-positive client
- D. B-positive blood to an AB-positive client
Correct Answer: B
Rationale: The greatest likelihood of an acute hemolytic reaction occurs when there is mismatch in the ABO blood group system, specifically when the recipient's plasma contains antibodies against the donor's red blood cells. In this scenario, giving O-positive blood to an A-positive client presents the highest risk because the A-positive client has anti-B antibodies in their plasma, which can attack the B antigens present on the O-positive donor red blood cells. This mismatch can lead to rapid destruction of the transfused red blood cells, causing an acute hemolytic reaction. It is crucial to ensure ABO compatibility to prevent such life-threatening reactions during blood product transfusions.
A 17-year-old boy is admitted in sickle cell crisis. Which of the ff. events most likely contributed to the onset of the crisis?
- A. He started a new job last week.
- B. He had seafood for dinner last night.
- C. He walked home in a cold rain
- D. He has not exercised for a week. yesterday.
Correct Answer: C
Rationale: Walking home in a cold rain can trigger a sickle cell crisis in individuals with sickle cell disease. Exposure to cold temperatures or getting wet can lead to vasoconstriction, causing the blood vessels to narrow and slow down blood flow. This reduced blood flow can increase the likelihood of sickle cells sticking together and blocking blood vessels, leading to pain and tissue damage characteristic of a sickle cell crisis. It is essential for individuals with sickle cell disease to avoid exposure to extreme temperatures, including cold rain, to prevent the onset of a crisis.
Which is an important nursing action related to the use of tape and/or adhesives on preterm newborns?
- A. Avoid using tape and adhesives until skin is more mature.
- B. Use solvents to remove tape and adhesives instead of pulling on skin.
- C. Remove adhesives with warm water or mineral oil.
- D. Use scissors carefully to remove tape instead of pulling tape off.
Correct Answer: A
Rationale: An important nursing action related to the use of tape and/or adhesives on preterm newborns is to avoid using tape and adhesives until the skin is more mature. Preterm newborns have delicate and fragile skin that is more prone to damage and injury. Using tape and adhesives on immature skin can increase the risk of skin tears, irritations, and damage. It is recommended to wait until the skin matures and becomes less delicate before using tape or adhesives on preterm newborns to prevent skin-related complications.