Nokea
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: The correct answer is B: Use barrier techniques. When taking the blood pressure of a client with AIDS, using barrier techniques such as gloves and disposable equipment is crucial to prevent the transmission of the virus through blood or bodily fluids. Wearing a mask and gown (choice A) may not be necessary unless there is a risk of splashes or sprays. Washing hands thoroughly (choice C) is important, but alone may not provide sufficient protection. Choice D is incomplete.
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An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
- A. Risk for increased cardiac output related to fluid volume excess
- B. Disturbed sensory perception related to bleeding into tissues
- C. Alteration in tissue perfusion related to bleeding and diminished blood flow
- D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C
Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues.
Explanation:
1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output.
2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception.
3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body.
In summary, the correct answer is C because DIC can lead to altered tissue perfusion
Which patient is most at risk for fluid volume overload?
- A. The 40-year-old with meningitis
- B. The 60-year-old with psoriasis
- C. The 35-year-old with kidney failure
- D. The 2-year-old with influenza
Correct Answer: C
Rationale: The correct answer is C, the 35-year-old with kidney failure. Patients with kidney failure are at high risk for fluid volume overload due to the kidneys' inability to properly regulate fluid balance. This can lead to accumulation of excess fluids in the body, causing edema, hypertension, and heart failure. In contrast, choices A, B, and D are not at as high risk for fluid volume overload as patients with kidney failure, as their conditions do not directly impact fluid regulation in the body.
Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:
- A. Loosening constrictive clothing
- B. Opening the patient’s jaw and inserting a mouth gag
- C. Positioning the patient on his or her side with head flexed forward
- D. Providing for privacy
Correct Answer: B
Rationale: The correct answer is B because inserting a mouth gag during a convulsive seizure can obstruct the airway and pose a choking hazard. Step-by-step rationale: A: Loosening clothing helps improve ventilation. C: Positioning on the side with head flexed forward prevents aspiration. D: Providing privacy is important for patient dignity and confidentiality. B is incorrect as it can be harmful.
Which of the following symptoms most likely indicates that an infusion is infiltrated?
- A. Redness at the site
- B. Pain at the site
- C. Puffiness at the site
- D. Exudate at the site
Correct Answer: C
Rationale: The correct answer is C: Puffiness at the site. This indicates infiltration of the infusion, where the medication or fluid leaks into the surrounding tissue instead of entering the bloodstream. Puffiness is a sign of fluid accumulation due to the infiltration. Redness at the site (A) may indicate infection, pain (B) can be due to various reasons, and exudate (D) may suggest infection or irritation, but they are not specific to infiltration. Infiltration assessment involves checking for swelling, coolness, and blanching around the infusion site.
A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?
- A. neuropathy on her peripheral
- B. nephropathy
- C. carpal tunnel syndrome
- D. macroangiopathy
Correct Answer: A
Rationale: The correct answer is A: neuropathy on her peripheral. In diabetes, peripheral neuropathy is common, causing loss of sensation in the feet, making it difficult to feel injuries like stepping on a sharp object. This can lead to delayed detection of wounds, increasing the risk of infections and complications. Nephropathy (B) refers to kidney damage, carpal tunnel syndrome (C) involves compression of the median nerve in the wrist, and macroangiopathy (D) refers to large blood vessel disease, which are not directly related to the scenario described.