Nokea
Which of the following is a priority assessment for a client receiving intravenous vancomycin?
- A. Respiratory rate
- B. Blood pressure
- C. Urine output
- D. Hearing acuity
Correct Answer: D
Rationale: The correct answer is D, Hearing acuity. Vancomycin is known to cause ototoxicity, which can result in hearing loss. Monitoring the client's hearing acuity is crucial to detect any early signs of ototoxicity. Assessing respiratory rate, blood pressure, and urine output are important assessments in general patient care but are not the priority when specifically monitoring for vancomycin-induced ototoxicity.
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What should be included in the medical management of sickle cell crisis?
- A. Information for the parents including home care
- B. Provisions for adequate hydration and pain management
- C. Pain management and administration of iron supplements
- D. Adequate oxygenation and factor VIII
Correct Answer: B
Rationale: The correct answer is B: Provisions for adequate hydration and pain management. In managing a sickle cell crisis, it is essential to provide adequate hydration to prevent further sickling of red blood cells and ensure proper pain management to alleviate the severe pain associated with the crisis. While information for parents and home care may be important aspects of overall care, they are not specific to the immediate medical management of a sickle cell crisis. Administration of iron supplements is not recommended during a sickle cell crisis as it can potentially worsen the condition by promoting the production of more sickled red blood cells. Adequate oxygenation is crucial in sickle cell disease, but factor VIII is not typically part of the management of a sickle cell crisis.
What is the best position for a client experiencing a nosebleed?
- A. Sitting up and leaning forward
- B. Lying flat with a pillow under the head
- C. Sitting up and leaning back
- D. Lying on the side with the head elevated
Correct Answer: A
Rationale: The best position for a client experiencing a nosebleed is sitting up and leaning forward. This position helps prevent blood from flowing down the throat and reduces the risk of aspiration.
Choice B is incorrect as lying flat can lead to blood flowing down the throat. Choice C is also incorrect because leaning back may cause blood to flow backward into the throat. Choice D is incorrect as lying on the side with the head elevated is not the optimal position to manage a nosebleed effectively.
What is the most common method of attempted suicide?
- A. Hanging
- B. Drug overdose
- C. Gunshot
- D. Slashing the wrists
Correct Answer: B
Rationale: Drug overdose is the most common method of attempted suicide. While hanging, gunshot, and slashing the wrists are also methods used in suicide attempts, statistics show that drug overdose is the most prevalent method chosen by individuals attempting suicide. Hanging, gunshot, and slashing the wrists are indeed common methods as well, but drug overdose ranks highest in terms of frequency.
The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?
- A. Notify the healthcare provider of the findings.
- B. Ensure that the IV is infusing at the prescribed rate.
- C. Listen to lung sounds.
- D. Check under his back for evidence of bleeding.
Correct Answer: D
Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.
A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question?
- A. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- B. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
- C. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- D. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.