Nokea
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it is essential to assess the severity of the latex allergy to determine the appropriate precautions and interventions. By asking the patient to describe the type of reaction, the nurse can gather crucial information to ensure patient safety.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview prematurely is not appropriate without gathering important information about the allergy. Choice D is incorrect because documenting the allergy is important, but assessing the type of reaction should be the initial priority.
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Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: The correct answer is D, a behavior change. Urinary retention in older adults with a neurologic deficit can manifest as a behavior change, such as increased agitation, confusion, or restlessness due to discomfort from the inability to empty the bladder. Amnesia (A) is memory loss and not directly related to urinary retention. Hypertension (B) and hypotension (C) are related to blood pressure regulation and are not specific signs of urinary retention. In contrast, a behavior change (D) is a common and characteristic sign indicating urinary retention in this population.
Five girls were victims of wasp and bee bites. Emergency treatment for these includes:
- A. A poultice of sodium bicarbonate and water may give relief
- B. A weak solution of household ammonia also decreases pain and is safe to use
- C. A and B are correct
- D. None of these
Correct Answer: A
Rationale: The correct answer is A because a poultice of sodium bicarbonate and water can help neutralize the venom and reduce pain from wasp and bee bites. Sodium bicarbonate has alkaline properties that can counteract the acidic venom. Option B is incorrect as household ammonia can cause skin irritation and should not be applied to insect bites. Option C is incorrect because only option A is a safe and effective treatment for wasp and bee bites. Option D is incorrect as there is a suitable emergency treatment available.
Which of the following blood types would the nurse identify as the rarest?
- A. A
- B. AB
- C. B
- D. O
Correct Answer: B
Rationale: The correct answer is B (AB). AB blood type is the rarest because it is a result of inheriting both A and B alleles, making it less common in the population. AB individuals can only receive blood from other AB individuals due to their unique antigens. Blood types A, B, and O are more common in the population, with O being the most common as it is the universal donor. Blood type A and B are more common than AB since they only require one allele for their respective antigens. Thus, the rarity of AB blood type is due to the inheritance of both A and B alleles, making it the least common among the choices provided.
In teaching a female client who is HIV positive about pregnancy, the nurse would know more teaching is necessary when the client says:
- A. “The baby can get the virus from my placenta.”
- B. “I’m planning on starting on birth control pills.”
- C. “Not everyone who has the virus gives birth to a baby who has the virus.”
- D. “I’ll need to have a C-section if I become pregnant and have a baby.”
Correct Answer: B
Rationale: The correct answer is B because starting birth control pills does not protect against HIV transmission to the baby during pregnancy. The other choices demonstrate understanding of HIV transmission risks and prevention methods. A shows awareness of vertical transmission, C recognizes that not all babies born to HIV-positive mothers are infected, and D acknowledges the potential need for a C-section to reduce transmission risk. Starting birth control pills is unrelated to preventing mother-to-child HIV transmission during pregnancy.
Which of the ff. conditions places a patient at risk for respiratory complications following his splenectomy?
- A. A low platelet count
- B. Early ambulation
- C. An incision near the diaphragm
- D. Early discharge
Correct Answer: C
Rationale: The correct answer is C: An incision near the diaphragm. Following a splenectomy, an incision near the diaphragm can lead to respiratory complications due to potential irritation or injury to the diaphragm. This can result in impaired breathing and increased risk of respiratory issues such as pneumonia.
A: A low platelet count is not directly related to respiratory complications following a splenectomy.
B: Early ambulation is generally encouraged to prevent complications such as blood clots but does not specifically impact respiratory complications.
D: Early discharge may not directly lead to respiratory complications, as long as the patient is adequately monitored postoperatively.