NUR 213 Health Exam

Correct Answer: A

Epinephrine

Explanation:

Epinephrine is the first-line treatment for anaphylactic shock because it rapidly reverses airway obstruction, hypotension, and cardiovascular collapse by:

• Stimulating alpha-adrenergic receptors → Increases blood pressure by causing vasoconstriction


• Stimulating beta-1 receptors → Increases heart rate and cardiac output


• Stimulating beta-2 receptors → Relaxes bronchial smooth muscles, relieving bronchospasms and improving breathing

Administration:

• Given intramuscularly (IM) in the mid-thigh for immediate effect


• Can be repeated every 5–15 minutes if symptoms persist

Why the Other Choices Are Incorrect:

Furosemide (Lasix)

• A loop diuretic used for fluid overload or hypertension


• Does not treat the airway constriction, hypotension, or histamine reaction seen in anaphylaxis

Dobutamine

• A beta-1 agonist that improves cardiac output in heart failure


• While it increases blood pressure, it does not counteract bronchospasms or histamine release, making it ineffective as a first-line treatment for anaphylaxis

Methylprednisolone (Solu-Medrol)

• A corticosteroid that reduces inflammation and prevents delayed anaphylactic reactions


• However, it has a delayed onset (several hours), so it is not effective in an emergency

Summary:

For anaphylactic shock, epinephrine should be administered first because it rapidly reverses airway obstruction and hypotension. Other medications, such as antihistamines, corticosteroids, and IV fluids, may be used as adjunct treatments, but epinephrine is the priority intervention.

Answer: Lactated Ringer’s at 170 mL/hr

Rationale (Step-by-Step Analysis):

1. Review of Key Patient Factors:

• 85 years old – Higher risk for fluid overload and complications.


• History of CHF (Congestive Heart Failure) – Fluid balance is critical to prevent exacerbation.


• On Furosemide 20 mg IV q6h – High-dose diuretic therapy suggests active fluid management.


• Indwelling catheter with cloudy urine – Likely UTI contributing to confusion.


• Current symptoms: Confusion, cloudy urine, heavy sediment – May indicate infection, dehydration, or worsening CHF.

2. Evaluating Each Provider Order for Potential Risk:

✅ Placement of Sequential Compression Stockings – LOW RISK

• Helps prevent DVT due to limited mobility post-op.


• Does not pose immediate harm.

✅ Famotidine 20 mg IV – LOW RISK

• Given to prevent stress ulcers in hospitalized patients.


• No significant risk related to CHF, kidney function, or infection.

✅ Cefepime 2 gm IV q12h – LOW RISK

• Broad-spectrum antibiotic likely given for UTI.


• Should be monitored for renal function adjustment but does not pose immediate danger.

 Lactated Ringer’s (LR) at 170 mL/hr – HIGHEST RISK (Monitor Closely!)

• CHF patients are prone to fluid overload → This high IV fluid rate may worsen heart failure!


• Diuresis from furosemide is removing fluid, but giving high-volume LR can counteract this effect.


• Signs of worsening CHF:
  
  
  
  • Increased confusion (fluid shifting, cerebral edema, hypoxia).
  
  
  • Possible pulmonary congestion (shortness of breath, crackles in lungs).
  
  
  • Swelling, worsening urine output, weight gain from retained fluid.
  
  
  
  

3. Nurse’s Priority Action:

• Monitor closely for fluid overload:
  
  
  
  
  • Lung sounds (crackles, dyspnea)
  
  
  • Edema, weight gain
  
  
  • Oxygenation, worsening confusion
  
  
  
  


• Contact provider to reassess IV fluid rate:
  
  
  
  • CHF patients often require fluid restriction, not aggressive hydration.
  
  
  • The provider may switch to a slower rate or consider using normal saline instead of LR (which contains electrolytes that could affect acid-base balance).
  
  
  
  

Final Conclusion:

Lactated Ringer’s at 170 mL/hr is the order that should be monitored most closely due to the high risk of fluid overload in a patient with CHF.

Correct Answer:

B) The patient is infected with HIV but lacks HIV-specific antibodies.

Explanation:

The primary infection stage of HIV, also called acute HIV infection or acute retroviral syndrome, occurs 2 to 4 weeks after exposure to the virus. During this time:

• The virus rapidly replicates in the body.


• The immune system has not yet produced detectable HIV-specific antibodies, meaning standard HIV antibody tests (such as ELISA) may not detect the infection.


• Some patients experience flu-like symptoms (fever, swollen lymph nodes, rash, sore throat), while others remain asymptomatic.


• The viral load is very high, making the person highly infectious even if they feel well.

This stage progresses into the chronic (latent) phase once the immune system begins producing antibodies.

Why the Other Choices Are Incorrect:

• A) "The patient's HIV antibodies are successfully, but temporarily, killing the virus."
  
  
  
  
  • Incorrect. The immune system has not yet produced HIV-specific antibodies during the primary infection stage. Antibody production occurs weeks later in the chronic phase. Additionally, while the immune system fights the virus, it cannot eliminate HIV completely.
  
  
  
  


• C) "The patient's risk for opportunistic infections is at its peak."
  
  
  
  • Incorrect. Opportunistic infections (e.g., Pneumocystis pneumonia, Kaposi’s sarcoma) occur in late-stage HIV/AIDS, when the CD4+ T-cell count falls below 200 cells/mm³. In the primary infection stage, the immune system is still functioning relatively well, so the risk for opportunistic infections is low.
  
  
  
  


• D) "The patient may or may not develop long-standing HIV infection."
  
  
  
  • Incorrect. Once infected, a person will have HIV for life unless they receive an extremely rare, complete HIV cure (e.g., through experimental treatments like bone marrow transplants). The infection does not "go away", though antiretroviral therapy (ART) can control it.
  
  
  
  

Summary:

In the primary infection stage of HIV, the virus is actively replicating, but HIV-specific antibodies are not yet detectable (B is correct). Opportunistic infections are not a concern at this stage, and HIV infection is lifelong once acquired.

Correct Answer:

(c) Stop the infusion and call the provider.

Explanation:

Tissue plasminogen activator (t-PA) is a clot-busting medication used to treat ischemic strokes, myocardial infarctions, and pulmonary embolisms by dissolving blood clots. However, it carries a major risk of intracranial hemorrhage (brain bleed).

• New-onset disorientation (confusion to person, place, and time) is a critical sign of a possible hemorrhagic stroke or bleeding in the brain.


• The priority action is to STOP the infusion immediately to prevent further bleeding.


• The next step is to call the provider STAT for urgent evaluation and possible reversal of t-PA effects.

Why the Other Options Are Incorrect:

• (a) Assess the client's pupillary responses – Incorrect
  
  
  
  
  • While assessing pupils is important, it is not the priority.
  
  
  • The first action must be to stop the t-PA to prevent worsening bleeding.
  
  
  
  


• (b) Request a neurologic consultation – Incorrect
  
  
  
  • A neurology consult may be needed, but it delays immediate intervention.
  
  
  • Stopping the infusion takes priority.
  
  
  
  


• (d) Take and document a full set of vital signs – Incorrect
  
  
  
  • Vital signs are important, but stopping t-PA must come first.
  
  
  • Bleeding can progress rapidly, so the infusion must be stopped immediately.
  
  
  
  

Key Takeaway:

Any sudden neurologic change in a client receiving t-PA is a medical emergency. The nurse must immediately stop the infusion and call the provider to prevent further complications.

Correct Answer: b. Ensure the balloon does not remain wedged.

Explanation (Why This Answer is Correct)

Hemodynamic monitoring involves the use of a pulmonary artery (PA) catheter, which can measure pulmonary artery wedge pressure (PAWP) to assess left ventricular function. The catheter has a balloon at the tip that, when inflated, momentarily occludes the pulmonary artery to obtain a pressure reading. If the balloon remains inflated (wedged), it can obstruct blood flow to the lungs, potentially causing pulmonary infarction or arterial rupture. The nurse must ensure the balloon is deflated after obtaining PAWP readings to prevent complications.

Why the Other Options Are Incorrect

a. Document PAWP readings and assess their trends

While monitoring PAWP trends is important for managing heart failure or shock, preventing a wedged balloon is a higher priority because a prolonged occlusion can cause serious complications.

c. Keep the client on strict NPO status

NPO status is not required for hemodynamic monitoring. Clients may have dietary restrictions if they are critically ill, but this is not a standard safety precaution for PA catheter management.

d. Maintain the client in a semi-Fowler’s position

Semi-Fowler’s position (30–45 degrees) is beneficial for clients with heart failure or respiratory distress, but positioning does not directly relate to PA catheter safety. Preventing a wedged balloon is more critical.

Summary

The most important safety precaution for a client with hemodynamic monitoring is ensuring the PA catheter balloon does not remain wedged. A prolonged wedge position can obstruct blood flow, leading to serious complications. Monitoring trends, positioning, or dietary restrictions do not directly prevent this life-threatening risk.

Correct Answer:

A) Providing thorough oral care before and after meals

Explanation:

In stage 3 HIV (AIDS), candidiasis (thrush) is a common opportunistic infection that affects the oral mucosa, skin folds, and genital areas. Proper oral care helps reduce fungal overgrowth, prevent discomfort, and maintain skin integrity by preventing irritation and secondary infections. Brushing with a soft toothbrush, using antifungal mouth rinses (like nystatin), and avoiding irritating foods are key interventions.

Why the Other Choices Are Incorrect:

• B) Administering prophylactic antibiotics:
  
  
  
  
  • Incorrect. Candidiasis is a fungal infection, not a bacterial one, so antibiotics are not effective. In fact, excessive antibiotic use can increase the risk of fungal overgrowth by killing beneficial bacteria.
  
  
  
  


• C) Promoting nutrition and adequate fluid intake:
  
  
  
  • Partially correct but not the best choice. Good nutrition and hydration support immune function and tissue repair, but they do not directly prevent skin breakdown from candidiasis like proper oral care does.
  
  
  
  


• D) Applying skin emollients as needed:
  
  
  
  • Incorrect. While moisturizing the skin can help with dryness and irritation, it does not specifically address candidiasis-related skin breakdown. Antifungal treatments (such as clotrimazole or nystatin) are more appropriate for managing fungal infections.
  
  
  
  

Summary:

For HIV/AIDS patients with candidiasis, thorough oral care (A) is the best nursing intervention to prevent impaired skin integrity, reduce fungal overgrowth, and maintain oral and skin health. Antibiotics are not useful, and while nutrition and skin hydration are helpful, they are not the most direct intervention for candidiasis-related skin risks.

Correct Answers: B, C. 

Six-month history of H. pylori

Alcohol abuse and smoking

Why These Answers Are Correct:

Six-month history of H. pylori

H. pylori infection is the most common cause of peptic ulcer disease (PUD). The bacteria weaken the protective mucosal lining of the stomach and duodenum, allowing stomach acid to create ulcers. Chronic infection can lead to gastritis, ulcers, and even stomach cancer if left untreated.

Alcohol abuse and smoking

Both alcohol and smoking increase the risk of PUD. Alcohol irritates the stomach lining and stimulates acid production, worsening ulcer formation. Smoking reduces blood flow to the stomach, impairs healing, and increases the risk of ulcer complications like bleeding and perforation.

Why the Other Choices Are Incorrect:

Active lifestyle and smoking

Smoking is a risk factor, but an active lifestyle does not contribute to PUD. Exercise generally benefits digestive health and does not cause ulcers.

Eating spicy foods and laid-back attitude

Spicy foods do not cause ulcers, though they may irritate existing ulcers. Stress and personality type ("laid-back attitude") are not direct causes of PUD, though chronic stress can worsen symptoms.

Occasional alcohol and cocaine use

Occasional alcohol consumption does not significantly increase PUD risk, unlike chronic alcohol abuse. Cocaine is not a direct risk factor for PUD, though it can reduce blood flow to the digestive tract, leading to ischemic ulcers in extreme cases.

Summary:

The primary risk factors for peptic ulcer disease include H. pylori infection, alcohol abuse, and smoking. Spicy foods, an active lifestyle, and occasional alcohol use do not significantly contribute to ulcer formation.

Correct Answer: A) Administer antidiarrheal medications on a scheduled basis, as ordered.

Explanation:

Severe diarrhea in HIV/AIDS patients can be caused by opportunistic infections (e.g., Cryptosporidium, CMV, Mycobacterium avium complex), medication side effects, or HIV enteropathy. Uncontrolled diarrhea can lead to dehydration, malnutrition, and electrolyte imbalances, making its management a priority. Administering antidiarrheal medications (e.g., loperamide, diphenoxylate/atropine) on a scheduled basis, as prescribed, is the most effective way to manage persistent diarrhea and improve the patient’s quality of life.

Why the Other Choices Are Incorrect:

B) Encourage the patient to eat three balanced meals and a snack at bedtime:

 While proper nutrition is important, small, frequent meals with bland, low-fiber foods (such as bananas, rice, applesauce, and toast) are better tolerated than large meals in patients with severe diarrhea.

C) Increase the patient's oral fluid intake:

Partially correct but not the best choice. Hydration is important to replace fluid losses, but without addressing the cause of diarrhea, the patient will continue losing fluids. Fluid replacement should be combined with antidiarrheal medications for effective management.

D) Encourage the patient to increase his or her activity level:

Increasing activity can worsen fatigue and fluid loss, leading to further dehydration in a patient with severe diarrhea. Rest and proper management of symptoms are more appropriate.

Summary:

For HIV/AIDS patients with severe diarrhea, administering antidiarrheal medications on a scheduled basis (A) is the most appropriate nursing intervention. Hydration and dietary adjustments are helpful but should not replace medication management. Increased activity is not recommended as it may exacerbate dehydration and fatigue.

Correct Answer: ✅ Potassium 10 mg IV mini bag

Rationale (Step-by-Step Breakdown):

1. Reviewing the Patient's Risk Factors:

• Elderly (85 years old) → Increased risk for medication errors, kidney impairment, and electrolyte imbalances.


• On Coumadin (warfarin) → Needs monitoring for bleeding risk.


• Receiving Furosemide (Lasix) IV → Causes potassium loss → High risk for hypokalemia.


• Indwelling urinary catheter → Likely developed a UTI, which may contribute to confusion.

2. Evaluating the Medication Orders:

✅ Discontinue indwelling catheter – Appropriate

• UTIs are common with catheters, and removing it reduces infection risk.

✅ Warfarin 5 mg PO – Appropriate but needs INR monitoring

• The dose itself is within a normal range, but the infection may increase INR levels, requiring closer monitoring.

✅ Regular insulin 5 units SC – Appropriate

• Likely ordered for stress-induced hyperglycemia from infection or post-op recovery.

 Potassium 10 mg IV mini bag – INCORRECT UNIT (Potentially Fatal Error!)

• Potassium is NEVER dosed in mg, only in milliequivalents (mEq).


• 10 mg ≠ 10 mEq → A dose of 10 mg is not a recognized IV potassium dose!


• IV potassium can be lethal if overdosed → Must be administered slowly with cardiac monitoring.

3. Correct Nursing Action:

🚨 Call the provider IMMEDIATELY to clarify and correct the potassium order!

• The provider likely meant 10 mEq instead of 10 mg.


• Administering potassium incorrectly can cause fatal cardiac arrhythmias.

Conclusion:

🔹 The most urgent issue is the incorrect potassium dose, as this is a medication error that could be life-threatening.

🔹 While Warfarin monitoring is important, the potassium order poses an immediate safety risk.

🔹 Always verify high-risk medications like potassium before administering.