Which of the following would the nurse use to document a finding that the patient’s ear is draining?

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Question 1 of 9

Which of the following would the nurse use to document a finding that the patient’s ear is draining?

Correct Answer: A

Rationale: The correct answer is A: Otorrhea. Otorrhea refers to the discharge of fluid from the ear, indicating an abnormal finding of ear drainage. This term specifically describes the symptom of ear drainage, making it the most appropriate choice for documenting this finding. Otalgia (choice B) refers to ear pain, ototoxic (choice C) refers to substances that are harmful to the ear, and tinnitus (choice D) refers to ringing in the ears, none of which accurately describe ear drainage. Therefore, the correct choice is A as it specifically addresses the symptom of ear drainage.

Question 2 of 9

A patient who is being tested for HIV asks what tests are used. The nurse would correct in stating that the tests used to confirm HIV infection are which of the following?

Correct Answer: B

Rationale: The correct answer is B: ELISA and Western Blot. The rationale is as follows: ELISA (enzyme-linked immunosorbent assay) and Western Blot are specific tests used to confirm HIV infection by detecting antibodies or antigens related to the virus. ELISA is the initial screening test, while Western Blot is the confirmatory test. These tests are highly sensitive and specific for HIV detection. Choice A is incorrect because CD4+ cell count and thymus function are not tests used to confirm HIV infection. They are used to monitor disease progression and immune function in HIV-positive individuals. Choice C is incorrect because B-cell and T-cell count are also not tests used to confirm HIV infection. They are indicators of immune system health but not specific for HIV diagnosis. Choice D is incorrect because while CD4+ and viral load tests are used in monitoring HIV progression, ELISA is the main confirmatory test for HIV diagnosis, and viral load is not typically used for initial

Question 3 of 9

An 83-year old client diagnosed with COPD has been receiving 1L of oxygen via nasal cannula. When the relatives visited, the sister of the client increased the oxygen to 7L per minute because she says that the client “looks like he is having difficulty getting air.” What should the nurse’s initial action be?

Correct Answer: C

Rationale: The correct initial action for the nurse is to choose option C: Notify the physician. Increasing oxygen without a healthcare provider's order can be harmful, especially in COPD patients prone to retaining carbon dioxide. The nurse should communicate the situation to the physician to assess the client's condition and adjust the oxygen therapy appropriately. Option A is incorrect as it neglects the potential risks of high oxygen levels. Option B is incorrect as immediate decrease without proper assessment can be dangerous. Option D is not the priority when the client's oxygen therapy needs evaluation.

Question 4 of 9

A client on hemodialysis is complaining of muscle weakness and numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, ca 8.5 mg/dl. Which electrolyte imbalance is the client suffering from?

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In hemodialysis, potassium levels can be elevated due to impaired renal excretion. High potassium can lead to muscle weakness and numbness. The client's K level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), confirming hyperkalemia. Na, Cl, and Ca levels are within normal limits, ruling out hypernatremia, hypochloremia, and hypocalcemia as the client's primary electrolyte imbalance. Monitoring and managing hyperkalemia are crucial to prevent life-threatening complications like cardiac arrhythmias.

Question 5 of 9

The kidneys regulate acid-base balance by all of the following mechanisms except:

Correct Answer: B

Rationale: Rationale: The correct answer is B because the kidneys do not reabsorb carbon dioxide to regulate acid-base balance. Carbon dioxide is mainly regulated by the lungs through respiration. The kidneys regulate acid-base balance by excreting hydrogen ions, reabsorbing or excreting bicarbonate (HCO3-) into the blood, and retaining or excreting hydrogen ions. Reabsorbing carbon dioxide is not a mechanism utilized by the kidneys for acid-base balance. Choices A, C, and D are correct mechanisms involved in acid-base balance regulation by the kidneys.

Question 6 of 9

While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining the client’s medication history, the nurse should determine if the client keeps which medication on hand?

Correct Answer: A

Rationale: Rationale: A: Diphenhydramine hydrochloride (Benadryl) is an antihistamine commonly used to treat allergic reactions, including those from bee stings. It can help alleviate symptoms like itching and swelling. Keeping Benadryl on hand is crucial for managing an allergic reaction promptly. Other Choices: B: Guaifenesin (Robitussin) is an expectorant used to treat coughs, not allergic reactions. C: Pseudoephedrine hydrochloride (Sudafed) is a decongestant used for nasal congestion, not allergic reactions. D: Loperamide (Imodium) is an antidiarrheal used to treat diarrhea, not allergic reactions.

Question 7 of 9

Which of the following questions or statements would be an appropriate termination of the health history interview?

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.

Question 8 of 9

For a client in addisonian crisis, it would be very risky for a nurse to administer:

Correct Answer: A

Rationale: The correct answer is A: potassium chloride. In Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone. Potassium levels are typically elevated in Addisonian crisis due to decreased aldosterone. Administering potassium chloride can further increase potassium levels, leading to life-threatening cardiac arrhythmias. Hydrocortisone (B) is essential to replace cortisol, normal saline solution (C) helps with volume resuscitation, and fludrocortisone (D) replaces aldosterone. Administering potassium chloride would exacerbate the hyperkalemia in Addisonian crisis.

Question 9 of 9

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.

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