Nokea
When admitting a woman experiencing a spontaneous abortion at the ambulatory care center, the nurse notes that the admission form identifies the patient’s religion as Islam. What should the nurse understand about this patient?
- A. She should not receive any pork-derived products.
- B. She probably will not have purchased health insurance.
- C. Artificial contraception and abortion are prohibited.
- D. She will not be able to receive blood or blood products if an emergency develops.
Correct Answer: A
Rationale: Islamic dietary laws prohibit consumption of pork-derived products. While other options relate to Islamic beliefs, they are either incorrect assumptions or unrelated to immediate nursing care.
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What action should the nurse include in teaching Mr. Ross about skin care of the irradiated area?
- A. Applying ointment or lotion to the skin
- B. Washing the area with soap and water
- C. Keeping the area dry and open to air
- D. Massaging the area and exposing it to sunlight
Correct Answer: C
Rationale: Protecting the skin from irritation and moisture promotes healing.
For your patient with a CD4 count, less than 200, the most important nursing assessment would include
- A. Bowel movements.
- B. Urinary output.
- C. Fever.
- D. Blood pressure.
Correct Answer: C
Rationale: Fever can indicate opportunistic infections in immunocompromised patients.
Mrs. Blakely's postoperative course is otherwise uneventful, and she is fitted with corrective glasses. For Mrs. Blakely to adjust to wearing her new eyeglasses, it would be most important to teach her that
- A. the color of objects seen with the operated eye is much brighter
- B. her new glasses will be much heavier
- C. she will have binocular vision
- D. she will have considerable distortion in vision
Correct Answer: A
Rationale: After cataract surgery, colors may appear brighter due to the removal of the cloudy lens, which previously muted perception of certain wavelengths.
A client in the emergency department is being cared for by a nurse and has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. What is the nurse's priority intervention?
- A. Provide the client with supplemental oxygen at 5 L/min via facemask.
- B. Place the client in high-Fowler's position with their legs in a dependent position
- C. Give the client sublingual nitroglycerin
- D. Administer morphine sulfate IV
Correct Answer: A
Rationale: The correct answer is A: Provide the client with supplemental oxygen at 5 L/min via facemask. In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation. Supplemental oxygen helps increase oxygen levels and alleviate respiratory distress, reducing the workload on the heart. This intervention addresses the client's dyspnea and anxiousness by improving oxygen delivery.
Choice B is incorrect as placing the client in high-Fowler's position with legs in a dependent position can help with breathing but does not address the immediate need for oxygenation.
Choice C is incorrect as sublingual nitroglycerin is typically used for angina and not the priority intervention for cardiogenic pulmonary edema.
Choice D is incorrect as morphine sulfate IV may be indicated for pain relief and anxiety, but it is not the priority intervention to address the client's oxygenation needs in cardiogenic pulmonary edema.
A 43-year-old man came to the ED reporting that for short periods of time he feels detached from his body and sometimes he feels like he is floating. The patient states he had not taken any drugs and his drug toxicology test results are negative. What is your best response?
- A. Does this condition interfere with activities of daily living?
- B. Did you ever take hallucinogenic at any time in your life?
- C. Let me ask our psychiatrist to assess you.
- D. Do you have any other symptoms?
Correct Answer: C
Rationale: Referral to a psychiatrist addresses potential underlying psychiatric conditions causing these symptoms.