A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Safety: Morbidly obese patients are at higher risk of falls during transfers. 2. Assistance: Having two other personnel ensures safe transfer. 3. Weight distribution: Distributing the patient's weight among multiple helpers reduces strain. 4. Proper body mechanics: Allows for proper positioning and technique while assisting. Summary of why other choices are incorrect: B. Medication doesn't address the safety concern of transferring a morbidly obese patient. C. Reviewing activity orders is not the immediate action needed for the patient's first bathroom transfer. D. Offering a walker may not provide sufficient support for a morbidly obese patient during the transfer.

Correct Answer: A

Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious. Incorrect choices: B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC. C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV. D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.

Correct Answer: C

Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.

Correct Answer: C

Rationale: The correct answer is C (50% to 55% carbohydrate, 35% fat, and 10% to 15% protein) for managing diabetes. Carbohydrates impact blood sugar levels the most, so a moderate intake is crucial. The fat percentage is lower to reduce the risk of cardiovascular issues, common in diabetics. Protein intake is moderate for muscle maintenance. Choice A has higher fat and lower carbohydrate, not ideal for diabetes. Choice B has too high carbohydrate, which can spike blood sugar. Choice D has the highest carbohydrate percentage, which is not recommended for diabetes management.

Correct Answer: C

Rationale: The correct answer is C: “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.” Rationale: 1. Desmopressin is available in intranasal form for diabetes insipidus. 2. Nasal discharge or blockage may prevent proper absorption of the medication. 3. Instructing the client about this potential issue ensures optimal drug effectiveness. Summary: A: Incorrect. Temperature of desmopressin suspension doesn't affect its efficacy. B: Incorrect. A medical identification bracelet is necessary for chronic conditions like diabetes insipidus. D: Incorrect. Monitoring fluid intake and output is crucial when taking desmopressin.

Correct Answer: A

Rationale: The correct answer is A: When the WBC falls to 5,000mm3. This is because a low WBC count indicates potential bone marrow suppression from the drug. Resuming treatment at this point ensures the bone marrow has recovered enough to handle the drug's effects. Summary: - Choice B: Hair regrowth is not a reliable indicator of bone marrow recovery. - Choice C: A high WBC count suggests potential toxicity, not readiness for treatment. - Choice D: Anemia is a late sign of bone marrow suppression, not an appropriate indicator to resume treatment.

Correct Answer: B

Rationale: The correct answer is B because red, open sores on the oral mucosa are a common sign of stomatitis, which can be caused by chemotherapy. Stomatitis is characterized by inflammation and ulceration of the mouth lining. The other choices are incorrect because: A: White, cottage cheese-like patches are indicative of oral thrush, a fungal infection. C: Rust-colored sputum may indicate a respiratory condition or infection, not stomatitis. D: Yellow tooth discoloration is not typically associated with stomatitis, but can be caused by various factors such as poor oral hygiene or certain foods.

Correct Answer: D

Rationale: The correct answer is D: Patency of airway and adequacy of respiration. During the acute stage of an unconscious patient like Mr. Franco, ensuring the airway is open and that breathing is adequate is the top priority to maintain oxygenation and prevent complications like hypoxia. This assessment is crucial for immediate intervention and can be life-saving. A: Level of awareness and response to pain may provide important information but is secondary to ensuring a patent airway and adequate breathing in an unconscious patient. B: Pupillary reflexes and response to sensory stimuli are important neurological assessments, but airway and breathing take precedence in the acute stage to maintain vital functions. C: Coherence and sense of hearing are not as critical as assessing and maintaining the airway and breathing in an unconscious patient.

Correct Answer: B

Rationale: The correct answer is B: Quadriceps setting. After surgery, quadriceps setting exercises are crucial for preventing muscle atrophy and maintaining joint mobility. Bladder control (A) is important but typically not the major early problem. Client education (C) and use of aids for ambulation (D) are important aspects of care but not the primary concern immediately post-surgery. Quadriceps setting helps prevent complications and promote early mobility.