Nokea
Which of the following terms would indicate to the nurse that a substance is toxic to the ear?
- A. Otoplasty
- B. Ototoxic
- C. Otalgia
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Ototoxic. Ototoxic refers to substances that are harmful to the ear, potentially causing hearing loss or damage. The prefix "oto-" specifically relates to the ear. Otoplasty (A) is a surgical procedure to reshape the ear, not related to toxicity. Otalgia (C) refers to ear pain, not toxicity. Tinnitus (D) is a symptom of ringing in the ears, not directly related to toxicity. Therefore, the term "ototoxic" is the best indicator of a substance being toxic to the ear due to its specific reference to ear toxicity.
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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. Soap can irritate the skin and exacerbate the risk for impaired skin integrity in a client receiving radiation therapy. By avoiding soap, we minimize the risk of skin breakdown and promote skin healing.
B: Applying talcum powder can actually worsen skin irritation and should be avoided.
C: Wearing a lead apron is not relevant to the nursing diagnosis of risk for impaired skin integrity.
D: Removing thoracic skin markings is not necessary for skin integrity and may disrupt the treatment plan.
What is the causative agent in HIV/AIDS?
- A. trichomonas vaginalis
- B. Treponema pallidum
- C. Human, T-cell lymphotrophio virus
- D. Chlamydia tranchomatis
Correct Answer: C
Rationale: The correct answer is C: Human, T-cell lymphotrophic virus, as it is the causative agent for HIV/AIDS. This virus specifically targets and infects the body's T-cells, weakening the immune system. Trichomonas vaginalis, Treponema pallidum, and Chlamydia trachomatis are all different pathogens that do not cause HIV/AIDS. Trichomonas vaginalis is a protozoan parasite that causes trichomoniasis, Treponema pallidum causes syphilis, and Chlamydia trachomatis causes chlamydia. Therefore, the correct answer is C based on the specific viral agent responsible for HIV/AIDS.
The nurse understands that which of the ff. best describes the action of propanolol (Inderal)?
- A. It increases heart rate
- B. It decreases fluid volume
- C. It decreases cardiac output
- D. It increases cardiac contractility
Correct Answer: C
Rationale: Step-by-step rationale:
1. Propranolol is a beta-blocker that acts on the heart.
2. It blocks beta-adrenergic receptors, leading to decreased heart rate and contractility.
3. Decreased heart rate and contractility result in reduced cardiac output.
4. Therefore, the correct answer is C - It decreases cardiac output.
Summary: A, B, and D are incorrect because propranolol does not increase heart rate, fluid volume, or cardiac contractility.
During the evaluation phase, what key action does the nurse perform?
- A. Diagnose the client’s condition based on new information.
- B. Identify nursing interventions for client care.
- C. Determine the effectiveness of the care plan.
- D. Develop goals and outcomes for client care.
Correct Answer: C
Rationale: During the evaluation phase, the nurse performs the key action of determining the effectiveness of the care plan. This involves assessing whether the client's goals are being met, if interventions are achieving the desired outcomes, and if any modifications are necessary. This step is crucial to ensure the care plan is successful and the client's needs are being addressed appropriately.
Choice A is incorrect because diagnosing the client's condition is typically done in the assessment phase, not during evaluation. Choice B is incorrect as identifying nursing interventions is part of the planning phase. Choice D is incorrect as developing goals and outcomes is part of the planning phase as well. Overall, the evaluation phase focuses on assessing the effectiveness of the care plan rather than diagnosing, identifying interventions, or developing goals.
In which of the ff circumstances should a nurse avoid using midline and mid clavicular sites for IV therapy? Choose all that apply.
- A. To administer solutions with a pH greater than 5 and less than 9
- B. To administer antineoplastic chemotherapy
- C. To administer slow, low-volume infusions
- D. To administer high-pressure bolus injections
Correct Answer: B
Rationale: The correct answer is B: To administer antineoplastic chemotherapy. This is because antineoplastic chemotherapy agents are highly irritating and toxic to the surrounding tissues. Using midline and mid clavicular sites for IV therapy in this case can increase the risk of extravasation, leading to tissue damage and potential complications.
Incorrect choices:
A: To administer solutions with a pH greater than 5 and less than 9 - pH of the solution does not directly affect the choice of site for IV therapy.
C: To administer slow, low-volume infusions - Midline and mid clavicular sites can be appropriate for slow, low-volume infusions.
D: To administer high-pressure bolus injections - While midline and mid clavicular sites may not be ideal for high-pressure bolus injections, the question specifically mentions IV therapy, not bolus injections.