Nokea
The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
- A. “Never suction your tracheostomy; you might damage your trachea.”
- B. “”You should not feel bad about the tracheostomy – you should be feel lucky to be alive.”
- C. “Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals.”
- D. “Your tracheostomy will be cleaned each time you visit your doctor.”
Correct Answer: C
Rationale: The correct answer is C: “Be sure to protect your tracheostomy from pollutants such as powders, hair, and chemicals.” This instruction is appropriate because keeping the tracheostomy site clean and free from pollutants is crucial in preventing infections and complications. Powders, hair, and chemicals can lead to irritation and blockages, increasing the risk of infection.
Explanation of why other choices are incorrect:
A: “Never suction your tracheostomy; you might damage your trachea.” - This is incorrect because suctioning is a necessary part of tracheostomy care to clear secretions and ensure proper breathing.
B: “You should not feel bad about the tracheostomy – you should feel lucky to be alive.” - This is incorrect as it does not provide practical instructions for tracheostomy care and may not address the patient's emotional concerns adequately.
D: “Your tracheostomy will be cleaned each time you visit your doctor.” - This is
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A nurse is providing education to a client with newly diagnosed hypertension about the importance of adhering to prescribed medications. Which phase of the nursing process does this activity represent?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: C
Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care.
Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.
The nurse is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?
- A. Higher steroid levels are needed during
- B. Malignant hypertension will occur.
- C. Respiratory failure will result.
- D. Malignant hyperthermia will result.
Correct Answer: A
Rationale: The correct answer is A because abruptly stopping steroids can lead to adrenal insufficiency due to suppression of the adrenal glands. This can result in a sudden drop in cortisol levels, which are essential for various physiological functions. Patients on long-term steroid therapy need a gradual taper to allow the adrenal glands to resume cortisol production. Choices B, C, and D are incorrect as they do not directly relate to the physiological effects of stopping steroids abruptly.
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: The correct answer is C: platelets 18,000. A critically low platelet count can lead to life-threatening bleeding in the ICU. Normal platelet count ranges from 150,000 to 450,000. A count of 18,000 indicates severe thrombocytopenia. Immediate reporting is crucial for prompt intervention.
Rationale for why other choices are incorrect:
A: Hematocrit of 48% is within normal range (male: 42-52%, female: 37-47%).
B: paCO2 of 38 mm Hg is within normal range (35-45 mm Hg).
D: WBC count of 8000 is within normal range (4000-11000/uL).
In critical care settings, it is vital to prioritize and address life-threatening conditions promptly, hence the urgent need to report the critically low platelet count.
A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client’s platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:
- A. 135,000/ul
- B. 20,000/ul
- C. 75,000/ul
- D. 500/ul
Correct Answer: B
Rationale: The correct answer is B: 20,000/ul. A platelet count below 20,000/ul puts the client at the highest risk for cerebral hemorrhage due to severe thrombocytopenia. Platelets are essential for blood clotting, and a low count increases the risk of spontaneous bleeding, especially in critical organs like the brain. Choices A, C, and D have platelet counts that are higher than the critical level of 20,000/ul, so they do not pose as high a risk for cerebral hemorrhage. Option D, 500/ul, is extremely low and would likely lead to severe bleeding, but the critical threshold for cerebral hemorrhage is considered to be around 20,000/ul.