Question

The nurse is admitting an older patient from a nursing home to the medical surgical unit. During the physical examination, the nurse observes a shallow open reddish, pink wound bed without slough on the patient's buttocks (see below). How will the nurse stage this pressure injury?

Answer 1

Correct Answers:

Stage II

Rationale :

✅ Shallow open wound with a pink/red wound bed indicates partial-thickness skin loss, consistent with Stage II.

✅ No slough or eschar is present, differentiating from Stage III or IV.

✅ Epidermis and dermis are partially damaged but not full-thickness.

✅ Stage I involves only non-blanchable erythema, which is not case here.

✅ Early identification prevents progression to deeper tissue injury.

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Answer 2

Correct Answers:

The patient took the prescribed metformin today.

Rationale :

✅ Metformin should be held before contrast procedures due to lactic acidosis risk.

✅ IV contrast can cause acute kidney injury, increasing metformin accumulation.

✅ Reporting ensures safe timing of procedure and medication adjustments.

✅ Normal HbA1C or blood glucose levels are not immediate concerns.

✅ Prior assessment prevents renal complications.

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Answer 3

Correct Answers:

Oral ibuprofen 800 mg

Rationale :

✅ Pericarditis pain improves with anti-inflammatory agents (NSAIDs).

✅ Ibuprofen reduces pericardial inflammation effectively.

✅ Opioids (morphine, fentanyl) are not first-line for inflammatory chest pain.

✅ Acetaminophen lacks anti-inflammatory effects needed in pericarditis.

✅ Early NSAID use improves symptom relief and mobility.

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Answer 4

Correct Answers:

Pruritis
Dark colored urine
Light clay colored stool

Rationale :

✅ Pruritus results from bile salt accumulation in tissues during jaundice.

✅ Dark urine indicates bilirubin excretion in urine due to liver dysfunction.

✅ Clay-colored stool shows lack of bile pigment in intestines.

✅ Chest pain and fever are not icteric-phase symptoms.

✅ Recognizing these signs aids in monitoring liver function progression.

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Answer 5

Correct Answers:

deep diffuse chest pain radiating to interscapular area

Rationale :

✅ Thoracic aortic aneurysm typically causes deep chest/back pain due to pressure on surrounding tissues.

✅ Pain radiating to the interscapular area is characteristic.

✅ Tearing substernal pain suggests aortic dissection, not aneurysm.

✅ No neurological symptoms are expected in uncomplicated aneurysm.

✅ Early detection prevents rupture or dissection complications.

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Answer 6

Correct Answers:

Oprelvekin

Rationale :

✅ Oprelvekin stimulates platelet production (thrombopoiesis).

✅ Interferons are for viral infections, not thrombocytopenia.

✅ Filgrastim stimulates neutrophil production, not platelets.

✅ Epoetin alfa increases RBC production.

✅ Correct drug selection prevents bleeding complications in chemotherapy patients.

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Answer 7

Correct Answers:

“l will acetaminophen when I need medicine for pain, fever or a headache”

Rationale :

✅ Cirrhosis patients should avoid acetaminophen due to hepatotoxicity risk.

✅ Lactulose is appropriate to reduce ammonia levels, even with diarrhea.

✅ Vitamin B complex and iron help with nutritional deficiencies in liver disease.

✅ Diuretics help manage ascites and fluid retention.

✅ Patient education prevents drug-induced liver failure.

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Answer 8

Correct Answers:

“A plastic anemia is caused by a suppression of all bone marrow elements.”

Rationale :

✅ Pancytopenia occurs due to bone marrow suppression in aplastic anemia.

✅ It involves reduced RBCs, WBCs, and platelets.

✅ It is not caused by iron deficiency or RBC destruction.

✅ Metabolic oxygen demand does not play a role in aplastic anemia.

✅ Accurate understanding guides treatment like bone marrow transplant.

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Answer 9

Correct Answers

Blank 1 Correct Option: unstable angina
Blank 2 Correct Option: Nitroglycerin SL

Rationale :

✅ Unstable angina occurs at rest, with increasing frequency and severity.

✅ Pain lasting ≥10 minutes with rest suggests unstable pattern.

✅ Nitroglycerin SL relieves ischemic pain by vasodilation and reducing oxygen demand.

✅ Early treatment prevents progression to myocardial infarction.

✅ Other analgesics like fentanyl or hydromorphone are not first-line for angina.

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Answer 10

Correct Answers:

Numbness and tingling of extremities

Rationale :

✅ Peripheral neuropathy (tingling, numbness) is a serious adverse effect of antitubercular drugs like isoniazid.

✅ Early reporting prevents permanent nerve damage.

✅ GI upset and reddish-orange urine are expected and not urgent.

✅ Headache and nervousness are mild, self-limiting effects.

✅ Education on early reporting improves medication safety.

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QLexNursing

1 :
The nurse is admitting an older patient from a nursing home to the medical surgical unit. During the physical examination, the nurse observes a shallow open reddish, pink wound bed without slough on the patient's buttocks (see below). How will the nurse stage this pressure injury?

2 :
A patient with type 2 diabetes is admitted for an outpatient coronary arteriogram. Which information obtained by the nurse is most important to report to the health care provider before the procedure?

3 :
A patient who has had recent cardiac surgery develops pericarditis and complains of level 3 (0 to 10 scale) chest pain with deep breathing. Which of these ordered PRN medications will be the most appropriate for the nurse to administer?

4 :
A patient diagnosed with in the icteric phase (jaundiced phase) With bilirubin, Select the three (3) associated signs and symptoms the nurse expects during this phase?

5 :
The patient with a thoracic aorta aneurysm describes the classic symptoms of this disorder to the nurse. How did the patient describe the symptoms?

6 :
A patient who has received chemotherapy has a critically low platelet count. The nurse expects Which drug or drug class to be used to stimulate platelet cell production?

7 :
The home health nurse visits the patient who was recently diagnosed with cirrhosis to begin a home-care education program. Which statement by the patient indicates the need for further instructions?

8 :
The patent asks the nurse to explain the pathologic mechanism involved in aplastic anemia. Which of the following statements correctly explains aplastic anemia?

9 :
The patient reports chest pain that occurs with increasing frequency, severity, and duration, and even occurs at rest. The chest pain last at least 10 minutes

Correct Answers

10 :
The nurse is discussing adverse effects of antitubercular drugs with a patient Who has active tuberculosis. Which potential adverse effect of antitubercular drug therapy should the patient report to the prescriber?

QLexNursing

1 : The nurse is admitting an older patient from a nursing home to the medical surgical unit. During the physical examination, the nurse observes a shallow open reddish, pink wound bed without slough on the patient's buttocks (see below). How will the nurse stage this pressure injury?

2 : A patient with type 2 diabetes is admitted for an outpatient coronary arteriogram. Which information obtained by the nurse is most important to report to the health care provider before the procedure?

3 : A patient who has had recent cardiac surgery develops pericarditis and complains of level 3 (0 to 10 scale) chest pain with deep breathing. Which of these ordered PRN medications will be the most appropriate for the nurse to administer?

4 : A patient diagnosed with in the icteric phase (jaundiced phase) With bilirubin, Select the three (3) associated signs and symptoms the nurse expects during this phase?

5 : The patient with a thoracic aorta aneurysm describes the classic symptoms of this disorder to the nurse. How did the patient describe the symptoms?

6 : A patient who has received chemotherapy has a critically low platelet count. The nurse expects Which drug or drug class to be used to stimulate platelet cell production?

7 : The home health nurse visits the patient who was recently diagnosed with cirrhosis to begin a home-care education program. Which statement by the patient indicates the need for further instructions?

8 : The patent asks the nurse to explain the pathologic mechanism involved in aplastic anemia. Which of the following statements correctly explains aplastic anemia?

9 : The patient reports chest pain that occurs with increasing frequency, severity, and duration, and even occurs at rest. The chest pain last at least 10 minutes

Correct Answers

10 : The nurse is discussing adverse effects of antitubercular drugs with a patient Who has active tuberculosis. Which potential adverse effect of antitubercular drug therapy should the patient report to the prescriber?

1 :
The nurse is admitting an older patient from a nursing home to the medical surgical unit. During the physical examination, the nurse observes a shallow open reddish, pink wound bed without slough on the patient's buttocks (see below). How will the nurse stage this pressure injury?

2 :
A patient with type 2 diabetes is admitted for an outpatient coronary arteriogram. Which information obtained by the nurse is most important to report to the health care provider before the procedure?

3 :
A patient who has had recent cardiac surgery develops pericarditis and complains of level 3 (0 to 10 scale) chest pain with deep breathing. Which of these ordered PRN medications will be the most appropriate for the nurse to administer?

4 :
A patient diagnosed with in the icteric phase (jaundiced phase) With bilirubin, Select the three (3) associated signs and symptoms the nurse expects during this phase?

5 :
The patient with a thoracic aorta aneurysm describes the classic symptoms of this disorder to the nurse. How did the patient describe the symptoms?

6 :
A patient who has received chemotherapy has a critically low platelet count. The nurse expects Which drug or drug class to be used to stimulate platelet cell production?

7 :
The home health nurse visits the patient who was recently diagnosed with cirrhosis to begin a home-care education program. Which statement by the patient indicates the need for further instructions?

8 :
The patent asks the nurse to explain the pathologic mechanism involved in aplastic anemia. Which of the following statements correctly explains aplastic anemia?

9 :
The patient reports chest pain that occurs with increasing frequency, severity, and duration, and even occurs at rest. The chest pain last at least 10 minutes

10 :
The nurse is discussing adverse effects of antitubercular drugs with a patient Who has active tuberculosis. Which potential adverse effect of antitubercular drug therapy should the patient report to the prescriber?