Nokea
When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
- A. WBC count
- B. Capillary refill
- C. Amount and color of sinus drainage
- D. Comfort level
Correct Answer: C
Rationale: The correct answer is C: Amount and color of sinus drainage. Assessing the amount and color of sinus drainage is crucial in evaluating the effectiveness of nursing interventions for sinusitis discomfort as it indicates the presence of infection or inflammation. Changes in color or amount can signify improvement or worsening of the condition. WBC count (A) may indicate infection but doesn't directly reflect sinusitis discomfort. Capillary refill (B) assesses circulation, not sinusitis. Comfort level (D) is subjective and can vary among individuals, making it less reliable for assessing the effectiveness of interventions.
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What is an important consideration regarding TPN administration?
- A. IV site is kept aseptic while infusing the solution
- B. Feeding is poured into a pouch and then infused
- C. Solution is only hung for a maximum of 8 hours at a time
- D. New formula is added as needed so the line does not run dry
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Aseptic technique prevents infection at IV site.
2. TPN is a high-risk solution, requiring strict aseptic administration.
3. Contaminated site can lead to sepsis or other serious complications.
4. Choice B increases risk of contamination.
5. Choice C increases risk of bacterial growth.
6. Choice D may introduce air or contamination.
Summary:
Choice A is correct as it emphasizes infection prevention. Choices B, C, and D pose risks of contamination, bacterial growth, or air introduction.
The examiner shines a light in the patient’s eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner’s finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?
- A. Pupils 2 mm
- B. PERRLA
- C. Pupils constricted
- D. Pupils normal
Correct Answer: B
Rationale: The correct answer is B: PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation. This documentation reflects a comprehensive assessment of the pupils' response to light and accommodation. The pupils constricting from 4 to 2 mm bilaterally in response to light indicates they are reactive. Additionally, the eyes turning inward when focusing on a near object shows accommodation.
Choice A is not the best option because it only mentions the pupil size without capturing other important aspects of the assessment. Choice C is too vague, as it does not specify the exact response of the pupils. Choice D is incorrect because it does not provide a detailed description of the pupils' response to both light and accommodation. Therefore, option B is the most appropriate choice as it encompasses all the necessary components of the assessment.
A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?
- A. Comply with the timing of antiviral medication around meals
- B. Avoid exposure to harsh sunlight for about 2hrs after taking the medication
- C. Have the medications with plenty of fruit juice
- D. Have an increased dose of the medications if the symptoms worsen
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Timing: Antiviral medications should be taken as prescribed to maintain consistent drug levels in the body.
2. Around meals: Taking medications with or without food can affect absorption, so timing around meals helps with consistency.
3. Compliance: Following the timing instructions increases medication effectiveness and reduces the risk of drug resistance.
Other Choices:
B) Avoiding harsh sunlight: Not directly related to medication administration; may be a precaution for other reasons.
C) Having medications with fruit juice: This is not a standard instruction for antiviral medications; may not be suitable for all medications.
D) Increasing dose for worsening symptoms: This is dangerous and should only be done under healthcare provider supervision; self-adjusting medication doses can be harmful.
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In the scenario, the nurse failed to assess the patient's condition promptly after the patient complained of feeling dizzy and light-headed. Assessment is the first phase of the nursing process and involves collecting data to identify the patient's health status. By not reassessing the patient's vital signs and symptoms, the nurse missed an opportunity to detect the worsening condition. The other choices are incorrect because the error occurred before diagnosis (B), implementation (C), and evaluation (D) phases. In diagnosis, the nurse identifies the patient's problems; in implementation, the nurse carries out the care plan; and in evaluation, the nurse assesses the effectiveness of interventions.
A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:
- A. Maintain standard precautions
- B. Prepare for the possibility that the baby may be delivered by CS.
- C. Notify the obstetrician and nurse midwife about the vesicles as soon as possible.
- D. Apply antibiotic ointment to the vesicles and place the mother in reverse isolation
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor.
2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences.
3. Standard precautions should always be maintained to prevent the spread of infections.
4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.