Nokea
A hospital’s wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient’s dressing changes. Which action should the nurses take next?
- A. Include dressing change instructions and frequency in the care plan.
- B. Assume that the wound nurse will perform all dressing changes.
- C. Request that the health care provider look at the wound.
- D. Encourage the patient to perform the dressing changes.
Correct Answer: A
Rationale: The correct answer is A: Include dressing change instructions and frequency in the care plan. This is the correct action because it ensures consistency in care and communication among the nursing team. By documenting the dressing change instructions and frequency in the care plan, all nurses will have clear guidance on how to perform the dressing changes correctly and at the appropriate intervals. This promotes continuity of care and helps prevent errors or omissions in the dressing change process.
Option B is incorrect as it is not realistic to expect the wound nurse to perform all dressing changes. Option C is unnecessary unless there are specific concerns requiring the health care provider's attention. Option D is not appropriate as encouraging the patient to perform dressing changes may not be safe or feasible depending on the patient's condition.
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For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?
- A. Compression of blood vessels due to blood loss
- B. Increase in the circulating blood volume
- C. Inadequate renal perfusion
- D. Hypovolemia and shock
Correct Answer: D
Rationale: The correct answer is D: Hypovolemia and shock.
Rationale:
1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms.
2. These signs indicate inadequate perfusion due to reduced blood volume.
3. Hypovolemia can progress to shock if not addressed promptly.
Summary:
A: Compression of blood vessels is not directly related to low blood volume.
B: Increasing circulating blood volume would not occur in a client with low blood volume.
C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.
The cause of death of most AIDS patients who develop multiple opportunistic infections is/are the following: a.Weakened immune system impairs response to therapy
- A. AH of these (a, b, c)
- B. Weakened immune system impairs resistance to infection
- C. Infection cannot be treated effectively
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Most AIDS patients with multiple opportunistic infections die due to a weakened immune system impairing response to therapy. When the immune system is compromised, the body struggles to fight off infections effectively, even with treatment. This results in the infections becoming more severe and ultimately leading to death.
Summary of Other Choices:
B: Weakened immune system impairs resistance to infection - While this is true, it doesn’t directly address the cause of death in AIDS patients with multiple infections.
C: Infection cannot be treated effectively - This is not entirely accurate as infections can be treated, but the weakened immune system hinders the response to treatment.
Overall, Choice A is the most accurate as it directly links the weakened immune system to the inability to respond effectively to therapy, leading to fatal outcomes.
The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has two young children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?
- A. Tell the client’s spouse or partner to be supportive while she recovers.
- B. Encourage the client to proceed with the next phase of treatment.
- C. Recommend that the client remain cheerful for the sake of her children.
- D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.
Correct Answer: D
Rationale: The correct answer is D: Refer the client to the American Cancer Society’s Reach for Recovery program or another support program. This choice is the best option as it provides the client with additional support and resources specifically tailored to individuals coping with cancer and mastectomy. The Reach for Recovery program offers emotional support, education, and practical assistance which can immensely benefit the client during this challenging time.
A: Involving the client's spouse or partner is important, but support programs like Reach for Recovery can offer specialized assistance that may not be fully covered by the spouse's support alone.
B: While proceeding with the next phase of treatment is important, emotional support and coping mechanisms are equally crucial, which support programs can provide.
C: Asking the client to remain cheerful may put pressure on her and may not address her emotional needs adequately, unlike a support program that is designed to provide comprehensive support.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because it is important for the nurse to communicate directly with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter may undermine the patient's autonomy and dignity. It is crucial for the nurse to establish rapport and build a therapeutic relationship with the patient. Making eye contact with the patient (choice A) is a good nonverbal communication technique. Leaning forward while talking with the patient (choice C) shows attentiveness and engagement. Nodding periodically while the patient is speaking (choice D) demonstrates active listening and encourages the patient to continue sharing. However, speaking only to the patient's daughter (choice B) is the incorrect choice as it neglects the patient's role in the conversation and may lead to potential issues in communication and patient-centered care.
Which of the ff nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver
- B. Encourage the client to perform exercises
- C. Assess apical heart before administering digitalis
- D. Offer small frequent feedings
Correct Answer: C
Rationale: The correct answer is C: Assess apical heart before administering digitalis. This is important because digitalis can slow down the heart rate, so it is crucial to monitor the client's heart rate before giving the medication to prevent further decrease in cardiac output. Encouraging activities that engage the Valsalva maneuver (A) is contraindicated in clients with congestive heart failure as it can lead to increased intra-thoracic pressure and decreased venous return, worsening cardiac output. Encouraging the client to perform exercises (B) may also increase cardiac workload and exacerbate symptoms. Offering small frequent feedings (D) is generally beneficial for clients with congestive heart failure to prevent overeating and promote easier digestion, but it does not directly address the decreased cardiac output concern in this scenario.