Nokea
Which of the following would the nurse use to document a finding that the patient’s ear is draining?
- A. Otorrhea
- B. Otalgia
- C. Ototoxic
- D. Tinnitus
Correct Answer: A
Rationale: The correct answer is A: Otorrhea. Otorrhea refers to the discharge of fluid from the ear, indicating an abnormal finding of ear drainage. This term specifically describes the symptom of ear drainage, making it the most appropriate choice for documenting this finding. Otalgia (choice B) refers to ear pain, ototoxic (choice C) refers to substances that are harmful to the ear, and tinnitus (choice D) refers to ringing in the ears, none of which accurately describe ear drainage. Therefore, the correct choice is A as it specifically addresses the symptom of ear drainage.
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The nurse administers chemotherapeutic drugs to a client with cancer. What adverse effects are most common?
- A. Painful mouth sores
- B. Nausea and vomiting
- C. Frequent diarrhea
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapeutic drugs commonly cause nausea and vomiting due to their effect on the gastrointestinal system. This is because these drugs can irritate the stomach lining and trigger the vomiting center in the brain. Nausea and vomiting are well-documented side effects of chemotherapy and are often managed with antiemetic medications.
A: Painful mouth sores are a common side effect of some chemotherapeutic drugs, but they are not the most common adverse effect.
C: Frequent diarrhea can occur as a side effect of chemotherapy, but it is less common than nausea and vomiting.
D: Constipation is not a common adverse effect of chemotherapeutic drugs; in fact, diarrhea is more commonly seen.
A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)
- A. Rank all the patient’s nursing diagnoses in order of priority.
- B. Do not change priorities once they’ve been established.
- C. Set priorities based solely on physiological factors.
- D. Consider time as an influencing factor.
Correct Answer: A
Rationale: The correct answer is A because ranking all the patient's nursing diagnoses in order of priority allows the nurse to address the most critical needs first. By prioritizing based on the urgency and potential impact on the patient's health, the nurse can ensure that interventions are carried out effectively.
B is incorrect because priorities may need to be adjusted based on the patient's changing condition. C is incorrect as priorities should consider not only physiological but also psychological and sociological factors. D is incorrect because time is an influencing factor, but it should not be the sole consideration when prioritizing interventions.
Which of the ff symptoms is observed in the client with Right Sided Heart Failure?
- A. Dependent pitting edema
- B. Orthopnea
- C. Exertional dyspnea
- D. Hemoptysis CARING FOR CLIENTS UNDERGOING CARDIOVASCULAR SURGERY
Correct Answer: A
Rationale: Rationale: Right-sided heart failure leads to fluid backup in the body causing dependent pitting edema due to fluid accumulation in the lower extremities. Orthopnea and exertional dyspnea are typically seen in left-sided heart failure. Hemoptysis is associated with conditions like pulmonary embolism or lung cancer, not right-sided heart failure. Therefore, the correct answer is A as it directly correlates with the symptoms of right-sided heart failure.
A patient who is being tested for HIV asks what tests are used. The nurse would correct in stating that the tests used to confirm HIV infection are which of the following?
- A. CD 4+ cell count and thymus function.
- B. ELISA and Western Blot
- C. B-cell and T-cell count.
- D. CD 4+, viral load, and ELISA
Correct Answer: B
Rationale: The correct answer is B: ELISA and Western Blot. The rationale is as follows: ELISA (enzyme-linked immunosorbent assay) and Western Blot are specific tests used to confirm HIV infection by detecting antibodies or antigens related to the virus. ELISA is the initial screening test, while Western Blot is the confirmatory test. These tests are highly sensitive and specific for HIV detection.
Choice A is incorrect because CD4+ cell count and thymus function are not tests used to confirm HIV infection. They are used to monitor disease progression and immune function in HIV-positive individuals.
Choice C is incorrect because B-cell and T-cell count are also not tests used to confirm HIV infection. They are indicators of immune system health but not specific for HIV diagnosis.
Choice D is incorrect because while CD4+ and viral load tests are used in monitoring HIV progression, ELISA is the main confirmatory test for HIV diagnosis, and viral load is not typically used for initial
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: C
Rationale: The correct answer is C: Maintaining the integrity of the urinary system. This is crucial in preoperative preparation for a client with malignant tumors to prevent complications such as urinary obstruction or infection. Assessing symptoms of peritonitis (B) is important but not as critical as ensuring urinary system integrity. Insertion of an ostomy pouch (A) and nasogastric tube diversion procedure (D) may be necessary interventions for some cases, but they are not as essential as ensuring the urinary system's integrity to prevent serious complications.