The patient presents with fever for the last few days, sore throat and enlarged lymph nodes under the jaw. What is the appropriate response of the nurse when the patient asks about the cause of the enlarged lymph nodes?

Enlarged lymph nodes are associated with hypertensive heart disease."

"They are most likely enlarged as a result of the throat infection.

"You should probably see an oncologist to rule out lymphedema.

You probably have a blockage in the thoracic lymph duct"

Answer and Explanation

The Correct Answer is B

A. Enlarged lymph nodes are associated with hypertensive heart disease is not a correct association. Hypertension does not directly cause lymph node enlargement.
B. They are most likely enlarged as a result of the throat infection is the correct answer. Enlarged lymph nodes, especially under the jaw, are commonly seen in response to infections, particularly in the throat (such as a viral or bacterial infection like pharyngitis).
C. You should probably see an oncologist to rule out lymphedema is an unnecessary response at this time. Lymphedema usually presents with other symptoms, and the patient's symptoms (fever, sore throat, and localized lymph node enlargement) suggest an infection rather than cancer.
D. You probably have a blockage in the thoracic lymph duct is not a common cause of localized lymph node enlargement. Blockages in the thoracic duct would affect lymphatic flow more generally and would present with more systemic symptoms.

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Correct Answer is A

Explanation

A. A quiet, private environment is crucial for effective teaching, especially for something like wound care that requires patient focus and clear understanding. Minimizing distractions ensures the patient can concentrate on the instructions.
B. While written materials are helpful, they should not be the only method of teaching, especially for a hands-on skill like wound care. Personal, verbal instruction is necessary for proper technique.
C. Asking the roommate to be considerate may help reduce distractions, but it does not address the core issue of needing a quiet, focused environment for teaching.
D. While the home-health nurse can provide additional teaching, it is essential for the nurse to teach the patient immediately, while they are still in the hospital setting, for optimal understanding and retention of wound care procedures.

Correct Answer is ["33"]

Explanation

$ Flow rate (gtt/min)=60mL/hour×drop factor (gtt/mL)$

Given:

Rate = 200 mL/hour

Drop factor = 10 gtt/mL

$Flow rate=(200×10)/60=2000/60=33.3 gtt/min$

Answer: 33gtt/min (roundedtothenearestwholedrop)

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The patient presents with fever for the last few days, sore throat and enlarged lymph nodes under the jaw. What is the appropriate response of the nurse when the patient asks about the cause of the enlarged lymph nodes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse attempts to teach the patient about wound care in a loud semiprivate room with many distractions. Which is the appropriate action of the nurse?

Correct Answer is A

Explanation

The physician gives orders to infuse 1000 mL 0.9% NS at 200 mL/h for dehydration. Tubing drop factor is 10 gtt/mL. Calculate the flow rate in drops per minute.

Correct Answer is ["33"]

Explanation

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