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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.
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Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: For HIV positive clients, one of the most important nursing interventions is to provide referral to support groups and resources where they can find emotional support, information, and guidance. Support groups can offer a sense of community, a safe space to share experiences, and practical advice on living with HIV. These groups can also provide valuable resources on managing HIV, accessing treatment, and coping with any associated stigma or discrimination. By connecting HIV positive clients to support groups and resources, nurses can help them navigate the challenges of living with HIV and promote their overall well-being and quality of life. This intervention fosters a holistic approach to care that goes beyond just medical treatment to address the social, emotional, and psychological needs of the client.
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.
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
- A. Have her rate her pain on a 0 to 10 scale
- B. Administer antibiotics as ordered
- C. Administer an analgesic as ordered
- D. Teach the patient about causes and prevention of STDs
Correct Answer: B
Rationale: The first priority when a woman with pelvic inflammatory disease complains of lower abdominal pain is to administer antibiotics as ordered. Pelvic inflammatory disease is often caused by a bacterial infection, and prompt treatment with antibiotics is crucial to prevent complications such as infertility or chronic pelvic pain. Addressing the infection promptly is essential in managing the condition and preventing further spread of the infection. Once antibiotic therapy has been initiated, the nurse can proceed with other interventions such as pain management (C), patient education on STDs (D), and assessing pain level (A).
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
- A. Assessing for symptoms of nausea and malaise
- B. Encouraging the intake of low-sodium liquids, such as coffee or tea
- C. Monitoring neurological status
- D. Restricting tap water intake
Correct Answer: B
Rationale: Hyponatremia is a condition characterized by low levels of sodium in the blood. Encouraging the intake of low-sodium liquids, such as coffee or tea, can further dilute the sodium levels in the body and worsen the condition. Instead, it is important to restrict fluid intake and focus on providing appropriate electrolyte replacement. Monitoring the patient's neurological status is crucial as severe hyponatremia can lead to neurological symptoms such as confusion, seizures, and coma. Assessing for symptoms like nausea and malaise helps in understanding the patient's condition. Restricting tap water intake is also necessary to help manage hyponatremia by preventing further dilution of sodium levels.
The nurse interprets this as?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Respiratory alkalosis is a condition where there is a decrease in carbon dioxide levels in the blood due to hyperventilation, leading to an increase in pH. In respiratory alkalosis, the body is expelling too much carbon dioxide, causing the blood to become more alkaline. The nurse's interpretation of the situation as respiratory alkalosis suggests that the patient may be breathing rapidly or deeply, resulting in the elimination of excess carbon dioxide and a shift towards alkalosis.