Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?
- A. Opening the patient's window to the outside environment
- B. Turning on the patient's room ventilator
- C. Opening the door of the patient's room leading into the hospital corridor
- D. Failing to wear gloves when administering a bed bath
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct Answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
When is the most appropriate time for obtaining a sputum specimen for culture?
- A. Early in the morning
- B. After the patient eats a light breakfast
- C. After aerosol therapy
- D. After chest physiotherapy
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following statements about chest X-rays is false?
- A. There are contraindications for this test
- B. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist
- C. A signed consent is not required
- D. Eating, drinking, and medications are allowed before this test
Correct Answer: A
Rationale: The correct answer is A because there are contraindications for chest X-rays, such as pregnancy or concerns about radiation exposure. Patients may need to remove jewelry and metallic objects to prevent interference with the imaging. While a signed consent is typically not required for a routine chest X-ray, there are specific situations where consent may be necessary. It is essential for patients to follow fasting instructions before certain types of chest X-rays to obtain accurate results.
Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?
- A. Hemoglobinuria
- B. Chest pain
- C. Urticaria
- D. Distended neck veins
Correct Answer: A
Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.
What is required for effective hand washing?
- A. Soap or detergent to promote emulsification
- B. Hot water to destroy bacteria
- C. A disinfectant to increase surface tension
- D. All of the above
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.