The facility education nurse is providing a group of new nurses education regarding weaponized biological threats. When discussing anthrax, which of the following should be included as portals of entry? SELECT ALL THAT APPLY
Integumentary system
Endocrine system
Central nervous system
Renal system
Respiratory system
Correct Answer : A,C,E
Choice A reason: The integumentary system is a portal of entry for anthrax because the bacteria can enter through cuts or abrasions on the skin. This is called cutaneous anthrax, and it is the most common and least deadly form of anthrax infection.
Choice B reason: The endocrine system is not a portal of entry for anthrax because the bacteria do not affect the glands or hormones of the body. The endocrine system is mainly involved in regulating metabolism, growth, development, and reproduction.
Choice C reason: The central nervous system is a portal of entry for anthrax because the bacteria can spread to the brain and spinal cord from other parts of the body. This is called meningeal anthrax, and it is a rare and fatal complication of anthrax infection.
Choice D reason: The renal system is not a portal of entry for anthrax because the bacteria do not infect the kidneys or urinary tract. The renal system is mainly involved in filtering waste products and excess fluids from the blood.
Choice E reason: The respiratory system is a portal of entry for anthrax because the bacteria can be inhaled into the lungs. This is called inhalation anthrax, and it is the most deadly form of anthrax infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.
Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skincare, and comfort measures to the client.
Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.
Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Initiating a plan of care for a client who is postoperative from an appendectomy is not a task that the RN should delegate to the LPN, as it requires nursing judgment, critical thinking, and assessment skills that are beyond the scope of practice of the LPN. The RN is responsible for developing, implementing, and evaluating the plan of care for each client based on their individual needs, preferences, and goals. The RN can delegate some aspects of the plan of care to the LPN, such as performing routine tasks or monitoring the client's status, but the RN must supervise and evaluate the LPN's performance.
Choice B reason: Administering a tap-water enema to a client who is preoperative is a task that the RN can delegate to the LPN, as it is a standardized procedure that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, following the established policies and protocols of the facility. The RN should provide clear instructions and expectations to the LPN, such as the type, amount, and temperature of the solution, the position and comfort of the client, and the signs and symptoms to report. The RN should also verify that the LPN has completed the task and documented the outcome.
Choice C reason: Providing discharge instructions to a confused client's spouse is not a task that the RN should delegate to the LPN, as it involves teaching, counseling, and evaluating the client's and family's understanding and readiness for discharge. These are complex activities that require nursing judgment, communication skills, and evaluation skills that are beyond the scope of practice of the LPN. The RN is responsible for ensuring that the client and family receive adequate information and education about the client's condition, treatment, medications, follow-up care, and community resources. The RN can delegate some aspects of discharge planning to the LPN, such as collecting data or providing reinforcement of teaching, but the RN must supervise and evaluate the LPN's performance.
Choice D reason: Catheterizing a client who has not voided in 8 hours is a task that the RN can delegate to the LPN, as it is a standardized procedure that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, following the established policies and protocols of the facility. The RN should provide clear instructions and expectations to the LPN, such as the type and size of the catheter, the sterile technique, and the urine output measurement. The RN should also verify that the LPN has completed the task and documented the outcome.
Choice E reason: Obtaining vital signs from a client who is 6 hours postoperative is a task that the RN can delegate to the LPN, as it is a routine task that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, using appropriate equipment and techniques. The RN should provide clear instructions and expectations to the LPN, such as the frequency and parameters of vital signs monitoring. The RN should also verify that the LPN has completed the task and documented the outcome.
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