Nokea
Which of the following is an appropriate intervention for a patient experiencing a hypertensive crisis?
- A. Placing the patient in a supine position
- B. Administering a beta-blocker intravenously
- C. Encouraging the patient to drink fluids
- D. Applying a cold compress to the forehead
Correct Answer: B
Rationale: Administering a beta-blocker intravenously is the correct intervention for a patient experiencing a hypertensive crisis. Beta-blockers help quickly reduce blood pressure and prevent complications such as stroke or heart attack. Placing the patient in a supine position can worsen the condition by reducing venous return and increasing the workload of the heart. Encouraging the patient to drink fluids is not recommended as it can exacerbate hypertension by increasing fluid volume. Applying a cold compress to the forehead does not address the underlying cause of the hypertensive crisis and is unlikely to provide significant benefit.
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What is the most common sign of a localized infection?
- A. Fever
- B. Elevated white blood cell count
- C. Redness, warmth, and swelling at the site of infection
- D. Chills and shivering
Correct Answer: C
Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice B) can be seen in both localized and systemic infections. Chills and shivering (choice D) are more related to the body's response to fever and not specifically indicative of a localized infection.
A male client with TB returns to the clinic for daily antibiotic injections for a urinary infection. The client has been taking anti-tubercular medications for 10 weeks and states he has ringing in his ears. Which prescribed medication should the PN report to the HCP?
- A. Pyridoxine with a B complex multivitamin
- B. Gentamicin 160 mg IM daily
- C. Rifampin 600 mg PO daily
- D. Isoniazid 300 mg PO daily
Correct Answer: B
Rationale: The correct answer is B: Gentamicin 160 mg IM daily. Gentamicin is an aminoglycoside antibiotic that can cause ototoxicity, leading to ringing in the ears (tinnitus). This symptom should be reported to the HCP immediately, as it may indicate a need to adjust or discontinue the medication. Choice A, Pyridoxine with a B complex multivitamin, is not the cause of ototoxicity. Choices C and D, Rifampin and Isoniazid, are anti-tubercular medications but are not associated with causing ringing in the ears.
What is the function of the enzyme lactase in the digestive system?
- A. Breaks down lactose into glucose and galactose
- B. Breaks down proteins into amino acids
- C. Converts starch into maltose
- D. Breaks down fats into fatty acids
Correct Answer: A
Rationale: The correct answer is A: 'Breaks down lactose into glucose and galactose.' Lactase is an enzyme in the small intestine that specifically breaks down lactose, the sugar found in milk, into glucose and galactose for absorption. Choice B is incorrect because proteins are broken down into amino acids by protease enzymes. Choice C is incorrect because the enzyme amylase converts starch into maltose. Choice D is incorrect as lipase enzymes break down fats into fatty acids.
The PN and UAP enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?
- A. Obtain emergency help
- B. Feel for a carotid pulse
- C. Bring a glucometer to the room
- D. Check the blood pressure
Correct Answer: A
Rationale: The correct answer is to instruct the UAP to obtain emergency help first. When a client is unresponsive, it could indicate a life-threatening condition that requires immediate intervention. Ensuring emergency help is on the way is the priority to address the potentially critical situation. Feeling for a carotid pulse, bringing a glucometer, or checking the blood pressure are important assessments but should come after taking steps to secure immediate assistance.
A client post-mastectomy is concerned about the risk of lymphedema. What should the nurse include in the discharge instructions to minimize this risk?
- A. Wear compression garments on the affected arm.
- B. Avoid venipunctures and blood pressure measurements on the affected arm.
- C. Perform vigorous exercises to strengthen the affected arm.
- D. Keep the affected arm elevated at all times.
Correct Answer: B
Rationale: To minimize the risk of lymphedema after a mastectomy, it is essential to instruct the client to avoid venipunctures and blood pressure measurements on the affected arm. These procedures can lead to trauma or impede lymphatic flow, increasing the risk of lymphedema. Wearing compression garments helps manage lymphedema but is not preventive. Performing vigorous exercises can strain the affected arm and increase the risk of lymphedema. Keeping the affected arm elevated at all times is unnecessary and not an effective preventive measure against lymphedema.