NUR 213 Health Exam

Correct Answer: b. Nausea

Explanation:

Oral contraceptive therapy (OCT) commonly causes nausea, especially when a person first starts taking it. This occurs due to the estrogen component, which can irritate the stomach lining. Taking the pill with food or at bedtime can help reduce this side effect.

Why the Other Options Are Incorrect:

a. Dizziness

While hormonal changes can cause mild dizziness in some people, it is not a common side effect of oral contraceptives.

c. Tingling in the extremities

Tingling (paresthesia) is not a typical adverse effect of oral contraceptives. However, it could indicate a more serious issue like blood clots, which are a rare but serious complication.

d. Polyuria

 Oral contraceptives do not cause increased urination. However, some formulations may cause fluid retention rather than excess urination.

Summary:

The most common side effects of oral contraceptives include nausea, breast tenderness, headache, and breakthrough bleeding. While dizziness and tingling could suggest other medical issues, polyuria is not a side effect of birth control pills.

Correct Answer: D) "I'll eat plenty of fruits and vegetables."

Explanation:

Fruits and vegetables provide essential vitamins (such as vitamin C) and minerals that support tissue repair and wound healing. Vitamin C is crucial for collagen synthesis, which strengthens the wound. Other nutrients like zinc and vitamin A also promote cell growth and immune function, aiding in wound healing.

Why the Other Choices Are Incorrect:

A) "I'll make sure to limit my intake of protein."

Incorrect because protein is essential for wound healing. A high-protein diet supports tissue repair, immune function, and collagen formation.

B) "I'll make sure that the bandage is wrapped tightly."

Incorrect because excessively tight bandaging can impair circulation. Proper compression may help if ordered for venous ulcers, but it should not be too tight, as it can compromise blood flow and delay healing.

C) "My foot should feel cool or cold while my leg's healing."

Incorrect because a cool or cold foot may indicate poor circulation, which can delay healing. A warm foot with good blood flow is necessary for proper oxygen and nutrient delivery to the healing tissue.

Key Takeaway:

A well-balanced diet rich in fruits, vegetables, and protein is essential for optimal wound healing.

Answers Indicating the Need for More Teaching: 

"I give the medication every 12 hours, and I can place it in a bit of formula so I know the baby will take it."

"If the baby vomits, I should give a second dose."

Explanation of Incorrect Answers (Needing More Teaching):

"I give the medication every 12 hours, and I can place it in a bit of formula so I know the baby will take it."

Incorrect practice: Digoxin should not be mixed with formula or food, as the baby may not finish the entire amount, leading to an incomplete dose. It should be given directly into the mouth using an oral syringe to ensure proper dosage.

"If the baby vomits, I should give a second dose."

Incorrect practice: If the baby vomits after receiving digoxin, do not give another dose unless directed by a healthcare provider. Vomiting can be a sign of digoxin toxicity, so administering an extra dose could lead to dangerous toxicity.

Explanation of Correct Responses (Indicating Understanding):

"I know I give the drug carefully by slowly directing it to the side and back of the mouth."

Correct: This is the appropriate method to ensure the infant swallows the medication properly without choking.

"If I miss a dose, I don't give an extra dose, but I give the next dose as ordered."

Correct: Missing a dose should not be followed by a double dose, as this can increase the risk of digoxin toxicity. The parent should wait until the next scheduled dose.

"If more than two doses have been missed, I should call the doctor."

Correct: Missing multiple doses can affect the drug’s effectiveness, and the doctor should be consulted for guidance on whether to resume normal dosing or adjust the regimen.

Summary:

The father needs more teaching regarding not mixing digoxin with formula and not giving a second dose if the baby vomits. These errors could lead to incorrect dosing or toxicity. Proper education on administration techniques, missed doses, and toxicity signs is crucial for safe home management of digoxin therapy in infants.

Correct Answer:

D) "It's possible that your baby could contract HIV, either before, during, or after delivery."

Explanation:

HIV can be transmitted from an HIV-positive mother to her baby through:

• Pregnancy (placental transmission)


• Delivery (exposure to blood and vaginal secretions)


• Breastfeeding (HIV can be present in breast milk)

However, with proper interventions, the risk of transmission can be reduced to less than 1%. Antiretroviral therapy (ART) during pregnancy, C-section if needed, and avoiding breastfeeding significantly decrease the risk. The nurse should provide factual, reassuring, and nonjudgmental information while encouraging the patient to follow medical recommendations.

Why the Other Choices Are Incorrect:

• A) "There is no way to know that for certain, but we do know that your baby has a one in four chance of being born with HIV."
  
  
  
  
  • Incorrect. The 1 in 4 (25%) statistic reflects the risk without any treatment. However, with proper ART, prenatal care, and delivery precautions, the risk is less than 1%, so this statement is misleading.
  
  
  
  


• B) "Your physician is likely the best one to ask that question."
  
  
  
  • Incorrect. While the physician plays a key role, nurses are responsible for providing patient education. Redirecting the question dismisses the patient’s concerns rather than empowering her with knowledge.
  
  
  
  


• C) "If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to worry about it now."
  
  
  
  • Incorrect. This response is inaccurate and dismissive. There are steps that can be taken during pregnancy to reduce transmission, such as ART, safe delivery methods, and avoiding breastfeeding. Telling the patient to "not worry" invalidates her concerns.
  
  
  
  

Summary:

The best response is D, as it provides accurate, evidence-based information about HIV transmission risks and emphasizes that interventions are available to protect the baby. The nurse should also encourage adherence to ART and prenatal care to lower transmission risk.

Correct Answer: C) Aplastic anemia

Why This Answer Is Correct:

Zidovudine (AZT) is a nucleoside reverse transcriptase inhibitor (NRTI) used to treat HIV-1. Aplastic anemia (bone marrow suppression) is a serious adverse effect of zidovudine, leading to decreased red blood cells, white blood cells, and platelets. The nurse should monitor the client for signs of anemia (fatigue, pallor), neutropenia (infection risk), and thrombocytopenia (bleeding tendencies).

Why the Other Choices Are Incorrect:

Metabolic alkalosis

Zidovudine is not known to cause metabolic alkalosis. Instead, it may cause lactic acidosis, a rare but serious complication

Renal failure

Zidovudine is not primarily nephrotoxic. While kidney function should be monitored, it does not commonly cause renal failure.

Cardiac dysrhythmia

Zidovudine does not directly cause cardiac dysrhythmias. Some clients may experience myopathy or cardiomyopathy, but arrhythmias are not a primary adverse effect.

Summary:

The nurse should closely monitor for aplastic anemia, a serious side effect of zidovudine, by checking CBC levels and watching for signs of anemia, neutropenia, and thrombocytopenia.

Priority Orders (Select 4)

1️⃣ Cefepime 2 grams IV every 12 hours ✅

• Rationale: Broad-spectrum IV antibiotics should be initiated as soon as sepsis is suspected. Early antibiotic administration is critical in preventing worsening infection and sepsis-related complications.

2️⃣ Stat lactate level ✅

• Rationale: Elevated lactate levels indicate tissue hypoxia and worsening sepsis. A lactate level >2 mmol/L suggests possible sepsis, and >4 mmol/L indicates septic shock, requiring immediate intervention.

3️⃣ Obtain a set of blood cultures ✅

• Rationale: Before starting antibiotics, blood cultures must be obtained to identify the causative organism and ensure appropriate antibiotic therapy.

4️⃣ Discontinue indwelling catheter ✅

• Rationale: The catheter is a likely source of infection, and removal helps reduce bacterial colonization and prevent further complications.

Non-Priority Orders (Not Selected)

Fingerstick glucose every 6 hours

• Rationale: Hyperglycemia can occur in stress responses, but glucose monitoring is not a primary intervention in suspected sepsis.

Discontinue Furosemide

• Rationale: Stopping diuretics abruptly in a CHF patient could lead to fluid overload. The provider should reassess fluid balance first.

1000mL Lactated Ringer's at 170mL/hr

• Rationale: Aggressive fluid resuscitation must be carefully considered in a CHF patient, as excess fluids may worsen heart failure. A more cautious approach with monitoring would be preferred.

Final Priorities

✅ Administer IV Cefepime

✅ Obtain stat lactate level

✅ Draw blood cultures

✅ Discontinue the indwelling catheter

💡 These actions align with the Surviving Sepsis Campaign and focus on infection control, identifying severity, and initiating treatment

Correct Answer: d. Prepare to administer a fluid bolus.

Explanation (Why This Answer is Correct)

A right atrial pressure (RAP) of 0.5 mm Hg is abnormally low, indicating hypovolemia or decreased preload. The right atrium receives blood from the body and sends it to the right ventricle. When RAP is low, there is not enough blood returning to the heart, leading to decreased cardiac output and perfusion. Administering a fluid bolus increases blood volume, raises RAP to a normal level (2–6 mm Hg), and improves circulation.

Why the Other Options Are Incorrect

a. Level the transducer at the phlebostatic axis

Proper transducer positioning ensures accurate readings, but a RAP of 0.5 mm Hg is truly low, not an artifact of incorrect leveling. The priority is to correct hypovolemia with IV fluids.

b. Lay the client in the supine position

Positioning alone will not correct hypovolemia. While lying supine can increase venous return temporarily, it does not address the underlying fluid deficit.

c. Prepare to administer diuretics

Diuretics remove excess fluid and are used when RAP is high, such as in fluid overload or heart failure. Since the RAP is low, giving diuretics would worsen the problem by further reducing blood volume.

Summary

A RAP of 0.5 mm Hg indicates low blood volume, requiring IV fluid replacement to restore normal circulation. Other interventions do not address the fluid deficit and would not help the client. Administering a fluid bolus is the best course of action.

Correct Answer: (b) Atrial fibrillation

Explanation:

Mitral valve regurgitation (MVR) occurs when the mitral valve does not close properly, causing blood to flow backward into the left atrium during systole. This increases left atrial pressure and volume, leading to left atrial enlargement, which predisposes the client to atrial fibrillation (AFib). AFib is a common complication of MVR due to the structural and electrical remodeling of the atrium.

Why the Other Options Are Wrong:

(a) Premature ventricular contractions (PVCs)

PVCs originate in the ventricles, often due to ischemia, electrolyte imbalances, or stimulant use. They are not typically associated with MVR, which affects the left atrium.

(c) Symptomatic bradycardia

MVR usually leads to tachyarrhythmias (such as AFib) rather than bradycardia. Symptomatic bradycardia is more commonly seen in conditions affecting the sinus node or conduction system.

(d) Sinus tachycardia

While tachycardia may occur as a compensatory mechanism, AFib is more directly associated with MVR due to atrial dilation and electrical instability.

Summary:

Clients with mitral valve regurgitation (MVR) are at high risk for atrial fibrillation due to left atrial enlargement. (b) Atrial fibrillation is the correct answer.

Correct Answer: (d) "Would you like information about advance directives?"

Explanation:

The client expresses concern about quality of life after the transplant, particularly the fear of being in a vegetative state. Discussing advance directives allows the client to make informed decisions about future medical care and communicate their wishes regarding life-sustaining treatments. Advance directives include living wills and durable power of attorney for healthcare, ensuring the client’s preferences are respected.

Why the Other Options Are Wrong:

(a) "Would you like to speak with a priest or chaplain?"

Spiritual support can be helpful but does not directly address the client’s specific concern about medical decisions. It could be offered later, but the priority is ensuring the client’s wishes are documented.

(b) "I will arrange for a psychiatrist to speak with you."

While mental health support is valuable, the client is expressing concerns about autonomy and medical decisions, not necessarily signs of clinical depression requiring psychiatry.

(c) "Do you want to come off the transplant list?"

This may sound dismissive or pressure the client to make an immediate decision. The priority is to provide information so they can make an informed choice.

Summary:

Discussing advance directives empowers the client to document their healthcare preferences, ensuring their values and wishes are respected in case of complications after the transplant.