Nokea
A female client age 66 is admitted ff a nephrolithomy. One of her laboratory tests reveals a urinary tract infection. Which would be the best nursing action in her case?
- A. Administer IV fluids and blood transfusions
- B. Administer narcotic analgesics as prescribed
- C. Encourage fluid intake of 3000ml/day
- D. Suggest taking herbs or spices to increase food palatability
Correct Answer: C
Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day
Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation.
Incorrect Choices:
A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection.
B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection.
D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.
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An adult has a central line in his right subclavian vein. The nurse is to change the tubing. Which of the following should be done?
- A. Use the present solution with the new tubing
- B. Connect the new tubing to the hub prior to running any fluid through the tubing
- C. Close the roller clamp on the new tubing after priming it
- D. Have the client roll to the right side to prevent an air embolus
Correct Answer: C
Rationale: The correct answer is C: Close the roller clamp on the new tubing after priming it. This step ensures that the tubing is primed with the solution and ready for use while preventing air from entering the central line. Option A is incorrect because using the present solution may introduce contamination. Option B is incorrect as connecting tubing before running fluid can introduce air into the line. Option D is incorrect as positioning the client on the right side does not prevent air embolism during tubing change.
During a breast examination, which finding most strongly suggests that the client has breast cancer?
- A. Slight asymmetry of the breasts
- B. A fixed nodular mass with dimpling of the overlying skin
- C. Bloody discharge from the nipple
- D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B
Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.
The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
- A. Actinic
- B. Asymmetry
- C. Arcus
- D. Assessment
Correct Answer: B
Rationale: The correct answer is B: Asymmetry. In the ABCD method for assessing skin lesions, A stands for asymmetry, which refers to whether one half of the lesion looks different from the other half. This is important because asymmetrical lesions are more likely to be cancerous. Actinic (choice A) refers to sun damage, Arcus (choice C) refers to a condition affecting the eyes, and Assessment (choice D) is a general term that does not specifically relate to the characteristics of skin lesions.
Which of the ff is the most severe complication among clients with allergies, regardless of type?
- A. Bronchitis
- B. Anaphylactic shock and angioneurotic
- C. Cardiac arrest edema
- D. Asthma and nasal polyps
Correct Answer: B
Rationale: The correct answer is B, anaphylactic shock and angioedema, as it is the most severe complication of allergies and can be life-threatening. Anaphylactic shock can lead to airway constriction, severe drop in blood pressure, and organ failure. Angioedema can cause swelling of the face, lips, and throat, leading to difficulty breathing. Bronchitis (A) is a respiratory condition that can occur due to allergies but is not typically life-threatening. Cardiac arrest (C) is a serious complication but not directly related to allergies. Asthma and nasal polyps (D) are common allergic conditions but are not as immediately life-threatening as anaphylactic shock.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis related to enhancing the patient's urinary elimination abilities through self-catheterization, which focuses on promoting the patient's health and well-being. The Readiness for enhanced urinary elimination diagnosis indicates the patient's motivation and readiness to improve their urinary elimination abilities, aligning with the concept of health promotion. This type of diagnosis acknowledges the patient's potential for growth and improvement in their health status.
Incorrect choices:
A: Risk - This choice would be more appropriate if the diagnosis focused on potential complications or adverse events related to the patient's urinary elimination abilities.
B: Problem focused - This choice would be suitable if the diagnosis identified an existing issue or problem with the patient's urinary elimination abilities that needed to be addressed.
D: Collaborative problem - This choice would be relevant if the diagnosis required collaboration between healthcare providers to manage the patient's urinary elimination abilities effectively.