Nokea
Which of the ff would help a client with an allergic skin reaction to reduce itching and maintain skin intact? Choose all that apply
- A. Humidifying the environment
- B. Avoiding a skin lubricant
- C. Bathing with a bar soap that contains lye
- D. Wearing cotton gloves, esp during sleep
Correct Answer: D
Rationale: The correct answer is D. Wearing cotton gloves, especially during sleep, helps reduce itching by preventing scratching, which can further irritate the skin. Cotton is a breathable fabric that reduces friction and irritation.
A: Humidifying the environment may help in some cases, but it doesn't directly address the itching or maintaining skin integrity.
B: Avoiding a skin lubricant is not recommended as it can help moisturize the skin and reduce itching.
C: Bathing with a bar soap that contains lye can be harsh and drying, exacerbating the skin reaction.
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Which laboratory study is monitored for the patient receiving heparin therapy?
- A. INR
- B. PTT
- C. PT
- D. Bleeding time
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect.
A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin.
C: PT (Prothrombin Time) is also used to monitor warfarin therapy.
D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: The correct answer is A. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process.
B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully.
C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood.
D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.
As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
- A. Dermatitis
- B. Sinusitis
- C. Delirium
- D. Wheezing
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Anaphylaxis is a severe allergic reaction that can lead to airway constriction and difficulty breathing, resulting in wheezing. Wheezing is a common symptom of anaphylaxis due to bronchospasm and airway swelling. Dermatitis (A) is a skin reaction, sinusitis (B) is inflammation of the sinuses, and delirium (C) is a state of mental confusion, which are not typical symptoms of anaphylaxis. Wheezing is a critical symptom in anaphylaxis as it indicates potential airway compromise and the need for immediate medical intervention.
. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
- A. Decreased serum sodium level
- B. Increased blood urea nitrogen
- C. Decreased serum creatinine level (BUN) level
- D. Increased hematocrit
Correct Answer: A
Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.
When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?
- A. moist gurgling respirations
- B. Distended neck veins
- C. Weak, slow pulse
- D. Dyspnea and coughing
Correct Answer: C
Rationale: The correct answer is C: Weak, slow pulse. Circulatory overload typically presents with signs of fluid volume excess, such as moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse is not a characteristic sign of circulatory overload, as the heart rate may actually be elevated due to the increased fluid volume. Therefore, a weak, slow pulse would not be likely to occur in this scenario.