Nokea
When the nurse obtains the nasal swab, which action is most accurate?
- A. The nurse dons sterile gloves before obtaining the specimen.
- B. The swab is placed in the anterior portion of the nare and swept superiorly.
- C. The client is asked to blow the nose before the specimen is collected.
- D. The nurse uses separate applicators for each nare.
Correct Answer: D
Rationale: Using separate applicators for each nare prevents cross-contamination and ensures an accurate sample for MRSA screening.
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Select all the factors regarding a deep vein thrombosis that are included in Virchow's Triad:
- A. Hypocoagulability
- B. Atherosclerosis
- C. Endothelial damage
- D. Stasis of venous blood
- E. Excessive coagulability
- F. Increased venous blood flow
Correct Answer: C,D,E
Rationale: Virchow's Triad details the THREE factors (hence why it called a triad) for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage.
A patient is presenting with chronic obstructive pulmonary disease. The patient has a chronic productive cough with dyspnea on excretion. Arterial blood gases show a low oxygen level and high carbon dioxide level in the blood. On assessment, the patient has cyanosis in the lips and edema in the abdomen and legs. Based on your nursing knowledge and the patient's symptoms, you suspect the patient suffers from what type of COPD?
- A. Emphysema
- B. Pneumonia
- C. Chronic bronchitis
- D. Pneumothorax
Correct Answer: C
Rationale: Chronic bronchitis , a type of COPD, is characterized by chronic productive cough, hypoxemia, hypercapnia, cyanosis, and edema from right heart failure. Emphysema typically shows barrel chest, pneumonia is an infection, and pneumothorax involves lung collapse.
Which question is most important for the nurse to ask the client at this time?
- A. When did you last take your prescribed medications?
- B. Have you taken all your medications as prescribed?
- C. How many drug refills have you obtained?
- D. Have you experienced any drug side effects?
Correct Answer: B
Rationale: Asking if the client has taken all medications as prescribed assesses adherence, which is critical for tuberculosis treatment efficacy.
Based on the client's clinical presentation, which drug should the nurse anticipate will be administered intravenously?
- A. Heparin
- B. Aminophylline (Truphylline)
- C. Nitroglycerin (Nitrodisc)
- D. Aspirin
Correct Answer: A
Rationale: Heparin is the standard anticoagulant used to prevent further clot formation in pulmonary embolism.
A patient is ordered by the physician to take Pulmicort and Spiriva via inhaler. How should the patient take this medication?
- A. The patient should use the medications every 2 hours for acute episodes of shortness of breath.
- B. The patient should use the Spiriva first and then 5 minutes later the Pulmicort.
- C. The patient should use the Pulmicort first and then the Spiriva 5 minutes later.
- D. The patient should use the medications at the same exact time, regardless of the order.
Correct Answer: B
Rationale: Spiriva (anticholinergic) should be used first to open airways, followed by Pulmicort (corticosteroid) 5 minutes later to reduce inflammation. Every 2 hours is incorrect for maintenance drugs, and order matters (C, D).