Nursing Elites

1. A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the healthcare provider?

• A. The Mantoux test induration measured 7 mm.
• B. The chest x-ray revealed infiltrates in the lower lobes.
• C. The patient is receiving antiretroviral therapy for HIV infection.
• D. The patient has a cough producing blood-tinged mucus.

Correct answer: C

Rationale: The most critical information to communicate to the healthcare provider in a patient diagnosed with both HIV and active TB disease is that the patient is receiving antiretroviral therapy for HIV infection. This is crucial because drug interactions can occur between antiretrovirals used to treat HIV infection and medications used to treat TB. By informing the healthcare provider about the antiretroviral therapy, potential interactions can be assessed and managed effectively to optimize patient care. The other data provided, such as the Mantoux test result, chest x-ray findings, and presence of blood-tinged mucus, are important clinical information but are expected in a patient with coexisting HIV and TB and do not directly impact potential drug interactions between antiretrovirals and TB medications.

2. The nurse is assigned to care for a child who is scheduled for an appendectomy. Select the prescriptions that the nurse anticipates will be prescribed. Select one that doesn't apply.

• A. Initiate an IV line.
• B. Maintain an NPO status.
• C. Administer a Fleet enema.
• D. Administer intravenous antibiotics.

Correct answer: C

Rationale: For a child scheduled for an appendectomy, the administration of a Fleet enema is not typically required. An IV line is often initiated for fluid and medication administration, maintaining NPO status is necessary to prevent aspiration during surgery, and administering intravenous antibiotics may be part of the preoperative regimen. Therefore, the correct choice that does not apply in this case is administering a Fleet enema.

3. After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?

• A. Raise the siderails of the patient's bed
• B. Do not offer fluids, food, or any oral intake
• C. Check the temperature of the patient
• D. Teach the patient to avoid aspirin or NSAIDS

Correct answer: B

Rationale: After an endoscopic procedure with general anesthesia, the priority nursing consideration is to not offer fluids, food, or any oral intake to the patient. Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. Raising the siderails of the patient's bed is important for safety but not the immediate priority. Checking the patient's temperature may be important but is not the priority immediately after the procedure. Teaching the patient to avoid aspirin or NSAIDS is important for post-procedure care but is not the priority immediately after the endoscopic procedure.

4. You are caring for Thomas N., a 77-year-old man with edema in his legs and a fluid restriction. You have been assigned to weigh him daily. Based on these symptoms and the care he is receiving, what disorder is he most likely affected by?

• A. Diabetes
• B. Dementia
• C. Congestive heart failure
• D. Contiguous heart disease

Correct answer: C

Rationale: Thomas N.'s symptoms of edema in his legs and fluid restriction point towards congestive heart failure (CHF) rather than dementia or diabetes. In CHF, patients often present with dependent edema in their legs due to excessive blood volume, leading to fluid intake restrictions and a low-salt diet. Daily weight monitoring is crucial in CHF to assess fluid retention or loss. Diabetes primarily affects blood sugar levels, dementia is a cognitive disorder, and 'Contiguous heart disease' is not a recognized medical term, making choices A, B, and D incorrect in this scenario.

5. When administering a shot of Vitamin K to a 30-day-old infant, which of the following target areas is the most appropriate?

• A. Gluteus maximus
• B. Gluteus minimus
• C. Vastus lateralis
• D. Vastus medialis

Correct answer: C

Rationale: When administering medications to infants, it is common to use the vastus lateralis muscle in the thigh for injections. The preferred site is the junction of the upper and middle thirds of the vastus lateralis muscle. This area provides a good muscle mass for the injection and minimizes the risk of hitting nerves or blood vessels. The gluteus maximus and gluteus minimus are not typically used for infant injections due to the risk of injury to the sciatic nerve. The vastus medialis is not as commonly used as the vastus lateralis for infant injections.

Similar Questions