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Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
- A. Flashing lights
- B. Lens opacity
- C. Halos around lights A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET N
Correct Answer: C
Rationale: The correct answer is C: Halos around lights. This symptom is specific to acute angle-closure glaucoma due to increased intraocular pressure causing corneal edema. Halos around lights are caused by light diffraction through edematous cornea. Flashing lights and lens opacity are not typically associated with acute angle-closure glaucoma. Flashing lights may be seen in retinal detachment, while lens opacity is more commonly seen in cataracts.
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The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
- A. Has intercourse with just the spouse
- B. Makes a donation of a pint of whole blood
- C. Limits sexual contact to those without HIV antibodies
- D. Uses a'condom each time there is a sexual intercourse
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV.
2. It eliminates the risk of contracting HIV from multiple sexual partners.
3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV.
4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission.
Summary:
- Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV.
- Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.
Which of the following intravenous solutions is hypotonic?
- A. Normal saline
- B. Ringer’s lactate
- C. 0.45% saline
- D. 5% dextrose in normal saline A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET F
Correct Answer: C
Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell.
Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts.
5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.
Which of the ff is a nursing intervention when assessing clients with hypertension?
- A. The nurse takes the temperature when the client is in a standing, sitting, and then supine position
- B. The nurses teaches the client about non pharmacologic and pharmacologic methods for restoring BP
- C. The nurse takes BP in both arms when the client is in a standing, sitting, and then supine position
- D. The nurse weighs the client each morning
Correct Answer: B
Rationale: The correct answer is B because teaching the client about both non-pharmacologic and pharmacologic methods for managing hypertension is a crucial nursing intervention to empower the client in their self-care and treatment plan. This intervention helps the client understand the importance of lifestyle modifications and medication adherence in controlling blood pressure.
A: The nurse taking the temperature in different positions is not directly related to assessing hypertension.
C: Taking BP in different positions is important for orthostatic hypotension, not specifically for hypertension.
D: Weighing the client each morning is not a direct nursing intervention for assessing hypertension.
A client has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chorambucil might this reaction occur?
- A. Immediately
- B. 2 to 3 weeks
- C. 1 week
- D. 1 month
Correct Answer: B
Rationale: The correct answer is B: 2 to 3 weeks. Alopecia is a common adverse reaction to chlorambucil, a type of chemotherapy drug that can cause hair loss. Alopecia typically occurs around 2 to 3 weeks after the first administration of chlorambucil. This is because chemotherapy drugs affect rapidly dividing cells, including hair follicles. Hair loss is a well-known side effect of many chemotherapy drugs, and it is important for the nurse to educate the client about this potential side effect.
Incorrect choices:
A: Immediately - Hair loss does not occur immediately after the first administration of chlorambucil.
C: 1 week - Hair loss typically occurs later than 1 week after starting chemotherapy.
D: 1 month - While hair loss can occur within a month, it is more likely to happen sooner, around 2 to 3 weeks after starting the medication.
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
- A. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician.
- B. Slow the transfusion and monitor the client closely.
- C. Stop the transfusion, notify the blood bank, and administer antihistamines
- D. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank
Correct Answer: D
Rationale: The correct answer is D: Immediately stop the transfusion, infuse normal saline solution, notify the blood bank.
Rationale:
1. Stop the transfusion immediately to prevent further complications from the hemolytic reaction.
2. Infuse normal saline solution to maintain adequate hydration and support kidney function.
3. Notify the blood bank to report the adverse reaction and to return the blood products for further investigation and testing.
Summary of other choices:
A: Incorrect because infusing dextrose 5% in water (D5W) is not indicated for treating a hemolytic reaction. Calling the physician is important, but stopping the transfusion and notifying the blood bank are more critical.
B: Incorrect because slowing the transfusion may not be sufficient to manage the acute hemolytic reaction effectively.
C: Incorrect because administering antihistamines is not the appropriate treatment for a hemolytic reaction. Stopping the transfusion and notifying the blood bank are more urgent actions.