RN exams medical-surgical practice questions set 12

Correct answer:

The most appropriate intervention for managing hepatic encephalopathy in this patient receiving palliative care for end-stage liver disease is to administer lactulose or other ammonia-lowering agents to reduce ammonia levels. Hepatic encephalopathy is believed to be primarily caused by the accumulation of ammonia in the bloodstream due to compromised liver function. Lactulose works by acidifying the gut lumen, which facilitates the excretion of ammonia in the form of ammonium ions. By reducing ammonia levels, hepatic encephalopathy symptoms, such as confusion and altered mental status, can be improved. Initiating other supportive measures like managing precipitating factors, maintaining hydration, and addressing nutritional issues should also be part of the holistic approach in managing hepatic encephalopathy in palliative care. However, addressing the underlying cause by reducing ammonia levels with lactulose is the priority intervention in this scenario.

Correct answer:

The correct answer is C: Inform the client not to drive or sign legal papers for 24 hours. This is because belimumab can cause dizziness and fatigue as side effects, which may impair the client's ability to drive or make important decisions. It is crucial for the nurse to ensure the safety of the client and others by advising against these activities for 24 hours post-administration. Choice A: Observing the client for at least 2 hours is important for monitoring immediate adverse reactions, but it is not the most appropriate action in this scenario. Choice B: Instructing the client about the monthly infusion schedule is important for treatment adherence, but it is not the most immediate concern after the first dose administration. Choice D: Ensuring emergency equipment is working and nearby is important for safety precautions, but advising the client not to drive or sign legal papers is more directly related to the potential side effects of belimumab.

Correct answer:

The correct answer is B: Systemic release of vasoactive mediators. Anaphylaxis is a severe allergic reaction that is primarily caused by the systemic release of vasoactive mediators such as histamine, prostaglandins, and leukotrienes from mast cells and basophils. These mediators lead to widespread vasodilation, increased vascular permeability, bronchoconstriction, and systemic hypotension, resulting in the characteristic symptoms of anaphylaxis. Choice A (Immune complex deposition) is incorrect because anaphylaxis is not caused by the deposition of immune complexes but rather by the immediate hypersensitivity reaction. Choice C (Localized mast cell degranulation) is incorrect because anaphylaxis involves systemic mast cell degranulation leading to widespread effects throughout the body, not just localized reactions. Choice D (T cell activation) is incorrect because anaphylaxis is primarily mediated by IgE antibodies and mast cells, not T cells.

Correct answer:

The correct answer is B: leave the heel exposed. This is important because when applying an elastic bandage to a freshly healed burned leg, leaving the heel exposed helps to prevent constriction of circulation and allows for proper venous return. By leaving the heel exposed, pressure is not applied directly to the Achilles tendon or the heel area, which could impede circulation and cause discomfort. This also helps to prevent blistering of the new skin by ensuring proper blood flow and reducing the risk of pressure ulcers. Choice A is incorrect because a figure-8 style of wrap may not provide the necessary support and could potentially constrict circulation. Choice C is incorrect because applying the bandage too loosely may not provide the required support and could lead to inadequate compression. Choice D is incorrect because removing the bandage as soon as the patient starts to walk can compromise the healing process and increase the risk of injury.

Correct answer:

The correct answer is A. A second exposure to an allergen does not lead to the development of autoimmune disorders. The key mechanisms involved in autoimmune disorders are self-tolerance breakdown and immune system attacking self-antigens. Explanation: 1. B: Cross-reaction of antibodies formed against foreign antigens with self-antigens is a possible mechanism for autoimmune disorders. 2. C: Exposure of previously 'hidden' self-antigens to the adaptive immune system can trigger autoimmune responses. 3. D: Mutation followed by the appearance of membrane proteins not previously present can lead to autoimmune disorders, as the immune system may recognize these proteins as foreign. Summary: Choice A is incorrect because a second exposure to an allergen does not cause the immune system to target self-antigens, which is the hallmark of autoimmune disorders. Choices B, C, and D are more plausible mechanisms for the development of autoimmune disorders.

Correct answer:

The correct answer is B: Systemic release of vasoactive mediators. Anaphylaxis is a severe allergic reaction that is primarily caused by the systemic release of vasoactive mediators such as histamine, prostaglandins, and leukotrienes from mast cells and basophils. These mediators lead to widespread vasodilation, increased vascular permeability, bronchoconstriction, and systemic hypotension, resulting in the characteristic symptoms of anaphylaxis. Choice A (Immune complex deposition) is incorrect because anaphylaxis is not caused by the deposition of immune complexes but rather by the immediate hypersensitivity reaction. Choice C (Localized mast cell degranulation) is incorrect because anaphylaxis involves systemic mast cell degranulation leading to widespread effects throughout the body, not just localized reactions. Choice D (T cell activation) is incorrect because anaphylaxis is primarily mediated by IgE antibodies and mast cells, not T cells.

Correct answer:

Rationale for Correct Answer A: Bladder retraining involves encouraging regular bathroom visits and adequate fluid intake to improve bladder control. By encouraging the resident to drink plenty of fluids, even if incontinence is a problem, the bladder can be trained to hold urine for longer periods, reducing the frequency of accidents. Summary of Incorrect Choices: B: Keeping a record of the resident's bladder habits is essential in bladder retraining to track progress and identify patterns. Not keeping a record would hinder the effectiveness of the retraining process. C: Wearing gloves when handling body wastes is crucial for infection control and preventing the spread of pathogens. Not wearing gloves poses health risks to both the NA and the resident. D: It is not the NA's role to dictate the resident's urination time. The focus should be on encouraging proper bladder habits, not pressuring the resident, which can lead to anxiety and worsen the issue.

Correct answer:

The correct answer is B: leave the heel exposed. This is important because when applying an elastic bandage to a freshly healed burned leg, leaving the heel exposed helps to prevent constriction of circulation and allows for proper venous return. By leaving the heel exposed, pressure is not applied directly to the Achilles tendon or the heel area, which could impede circulation and cause discomfort. This also helps to prevent blistering of the new skin by ensuring proper blood flow and reducing the risk of pressure ulcers. Choice A is incorrect because a figure-8 style of wrap may not provide the necessary support and could potentially constrict circulation. Choice C is incorrect because applying the bandage too loosely may not provide the required support and could lead to inadequate compression. Choice D is incorrect because removing the bandage as soon as the patient starts to walk can compromise the healing process and increase the risk of injury.

Correct answer:

During a transurethral resection of the prostate (TURP), fluid irrigation is commonly used to distend the bladder and flush out tissue debris. However, it is important to prioritize preventing fluid overload in the patient. Limiting the duration of irrigation fluid instillation is a crucial action to prevent excessive fluid absorption and subsequent fluid overload. Prolonged irrigation may lead to an increased risk of fluid overload and electrolyte imbalances, which can result in serious complications such as hyponatremia and fluid volume excess. Monitoring the patient's serum electrolyte levels can be important, but limiting the duration of irrigation is a more immediate and proactive measure to prevent fluid overload. Administering diuretic medications before the procedure may not be appropriate without assessing the patient's specific fluid status and needs. Adjusting the irrigation fluid temperature, while important for hemostasis, does not directly

Correct answer:

The correct answer is A: The results indicate your child may have Turner syndrome. This is the best response because 45, X is the karyotype typically associated with Turner syndrome, a genetic condition where a female is missing part or all of one X chromosome. This response shows the nurse's knowledge of genetics and ability to interpret karyotype results accurately. Summary of incorrect choices: B: Your results are 45, X; you will have to wait to talk with the geneticist - This response delays providing crucial information to the parents and does not address their immediate concerns. C: Your results indicate that your daughter has a serious lifelong disease - This choice is too vague and alarming, lacking specificity about the condition associated with the karyotype results. D: I’m not sure; I’ll call the provider - This response shows a lack of knowledge on the nurse's part and does not offer any immediate information or reassurance to the parents.