Nokea
Your 54-year-old male HIV-positive patient has just expired. How should you care for this deceased patient?
- A. Bathe the patient, but it is still necessary to use standard precautions because the patient is deceased.
- B. Place the patient in a negative pressure isolated area of the morgue.
- C. Double shroud the patient to prevent the spread of infection.
- D. Bathe the patient using the same standard precautions you used when he was alive.
Correct Answer: D
Rationale: Even after a patient has expired, standard precautions should be maintained to prevent the spread of infection. Bathing the deceased patient should be done using the same standard precautions followed when the patient was alive. This includes using personal protective equipment and following proper infection control procedures. Choices A, B, and C are incorrect because standard precautions must still be adhered to even after the patient has passed away to ensure safety and prevent the transmission of infections.
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During which stage of anesthesia is a patient most likely to experience involuntary motor activity?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage VI
Correct Answer: B
Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements.
Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur.
Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage.
Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.
A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?
- A. Is the client's family present so the AP can show them how to turn the client?
- B. Has data been collected about specific client needs related to turning?
- C. Does the AP have time to change the client's central IV line dressing after turning her?
- D. Has the AP checked the client's pain level prior to turning her?
Correct Answer: B
Rationale: Before delegating the task of bathing and turning a client with end-stage cancer to an experienced assistive personnel (AP), the nurse must assess specific client needs related to turning. This assessment ensures that the delegated care is tailored to the client's individual requirements, promoting safe and effective care. Option A is incorrect because the presence of the client's family is not directly related to assessing the client's specific needs for turning. Option C is incorrect as it refers to a different task (changing the central IV line dressing) and is not directly related to the turning assessment. Option D is incorrect as checking the client's pain level, although important, is not directly related to the specific needs related to turning the client.
Which of the following is the best way for a nurse to improve quality of care?
- A. Recognize that physicians are among the health-care professionals interested in improving quality of care.
- B. Work with patients and families to improve healthcare.
- C. Collaborate with other health-care professionals, patients, and their families.
- D. Recognize that physicians are among the numerous professionals in health care.
Correct Answer: C
Rationale: The best way for a nurse to improve the quality of care is by collaborating with other health-care professionals, patients, and their families. By working together with the healthcare team, patients, and families, nurses can ensure a holistic approach to care delivery, leading to better outcomes. Choices A and D are incorrect as they focus solely on physicians, while choice B, though important, does not fully encompass the collaborative aspect necessary for comprehensive care.
Steven John has type 1 diabetes mellitus and receives insulin. Which laboratory test will the nurse assess?
- A. Potassium
- B. AST (aspartate aminotransferase)
- C. Serum amylase
- D. Sodium
Correct Answer: A
Rationale: The correct answer is A: Potassium. Patients with type 1 diabetes receiving insulin are at risk of developing hypokalemia due to insulin's effects on potassium levels. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. Choices B, C, and D are incorrect because AST, serum amylase, and sodium levels are not directly impacted by insulin therapy in type 1 diabetes and are not the primary concern that needs monitoring in this scenario.
Based on the signs and symptoms of erythema marginatum, Sydenham chorea, epistaxis, abdominal pain, fever, cardiac problems, and skin nodules in your 32-year-old female patient, what disorder would you most likely suspect?
- A. Leukemia
- B. Histoplasmosis
- C. Pneumocystis jiroveci
- D. Rheumatoid arthritis
Correct Answer: D
Rationale: The signs and symptoms described point towards rheumatoid arthritis. Erythema marginatum, Sydenham chorea, epistaxis, abdominal pain, fever, cardiac issues, and skin nodules are classic manifestations of rheumatic fever, which is a complication of untreated streptococcal infection. This condition can lead to rheumatoid arthritis over time. Choices A, B, and C are incorrect as they do not align with the provided signs and symptoms, and they are not associated with the clinical presentation described.