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Which of the ff is a critical task of a nurse during the uterosigmoidostomy procedure for treating a malignant tumor?
- A. Inspecting for bleeding or cyanosis
- B. Inspecting for symptoms of peritonitis
- C. Assessing the clients allergy to iodine
- D. Checking for signs of electrolyte losses
Correct Answer: A
Rationale: During a uterosigmoidostomy procedure for treating a malignant tumor, a critical task of the nurse is to inspect for bleeding or cyanosis. Bleeding can be a potential complication during surgery and needs to be promptly identified and managed by the nurse. Cyanosis, which is a bluish discoloration of the skin due to lack of oxygen, can indicate a lack of blood flow to the tissues. Both bleeding and cyanosis are serious issues that require immediate attention to prevent further complications and ensure the client's safety and well-being. Therefore, assessing and monitoring for these signs are crucial tasks for the nurse in this situation.
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understands that it is important that which of the following diagnostic tests is obtained to help prevent cardiac complications?
- A. Chest x-ray examination c.White blood cell count
- B. Throat culture
- C. Erythrocyte sedimentation rate
Correct Answer: C
Rationale: The erythrocyte sedimentation rate (ESR) is an important diagnostic test that can help identify inflammation in the body, including inflammation in the heart. Elevated ESR levels may indicate the presence of an underlying condition that could potentially lead to cardiac complications if left untreated. Regular monitoring of ESR levels can help in the early detection and prevention of cardiac issues. The other options (A. Chest x-ray examination, B. Throat culture, and D. White blood cell count) are not specific diagnostic tests for assessing cardiac complications.
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
- A. Affected area appears to enlarge
- B. Red streaks extend up the arm or leg
- C. Additional lymph nodes become
- D. Liver and spleen become enlarged
Correct Answer: A
Rationale: A nurse should notify the physician when caring for a client with lymphangitis under the following situations:
A 13-year-old boy is hospitalized for a femur fracture after being hit by a car while racing bikes. The parents are concerned about his judgment. The nurse should tell the parents that this behavior is:
- A. Typical of young teens.
- B. Related to hormonal surges during adolescence.
- C. An isolated incident that will not likely happen again.
- D. Related to underdeveloped judgment and impulse control in adolescence.
Correct Answer: D
Rationale: The adolescent brain is still developing, which can lead to poor judgment and impulsive behavior.
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
- A. E-rosette immunofluorescence
- B. Enzyme-linked immunosorbent assay
- C. Quantification of T-lymphocytes (ELISA)
- D. Western blot test with ELISA
Correct Answer: D
Rationale: The confirmatory test for HIV infection is a Western blot test. However, before a Western blot test is conducted, an initial screening test with high sensitivity, such as the enzyme-linked immunosorbent assay (ELISA), is typically performed. ELISA is used to detect the presence of HIV antibodies in the blood. If the ELISA test is positive, a Western blot test is then performed to confirm the presence of specific HIV antibodies. The Western blot test is a more specific test for HIV antibodies and is used to confirm the diagnosis. Therefore, in this case, the physician would most likely order a Western blot test following a positive ELISA test to confirm the client's HIV infection.
When administering an I.M. injection to an infant, the nurse in charge should use which site?
- A. Deltoid
- B. Dorsogluteal
- C. Ventrogluteal
- D. Vastus lateralis
Correct Answer: D
Rationale: When administering an intramuscular (I.M.) injection to an infant, the nurse should use the vastus lateralis muscle. This is the preferred site for infants as it provides a large muscle mass and is less likely to damage nerves and blood vessels compared to other sites. The vastus lateralis is located on the thigh and is easily accessible for injections in infants. It is important to select the appropriate site for I.M. injections in infants to ensure proper medication absorption and minimize the risk of complications.