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An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
- A. Potential for infection
- B. Self care deficit
- C. Alteration in infection
- D. Fluid volume excess
Correct Answer: A
Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.
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A client is undergoing peritoneal dialysis. Which of the ff is a major complication of the procedure that the nurse should monitor for?
- A. Internal hemorrhage
- B. Hydronephrosis
- C. Ecchymosis
- D. Peritonitis
Correct Answer: D
Rationale: The correct answer is D: Peritonitis. Peritonitis is a major complication of peritoneal dialysis due to infection of the peritoneum. It can lead to serious consequences if not treated promptly. The nurse should monitor for signs of peritonitis such as abdominal pain, cloudy dialysate, fever, and increased white blood cell count.
Internal hemorrhage (A), hydronephrosis (B), and ecchymosis (C) are not major complications specific to peritoneal dialysis. Internal hemorrhage can occur but is less common. Hydronephrosis is more related to obstruction of the ureters. Ecchymosis refers to bruising and is not directly associated with peritoneal dialysis.
The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
- A. Type A
- B. Type AB
- C. Type B
- D. Type O
Correct Answer: A
Rationale: The correct answer is A: Type A. Individuals with blood type A have a slightly higher risk of developing gastric cancer compared to other blood types. This is due to the presence of certain antigens associated with Type A blood that may increase susceptibility to gastric cancer. In this case, the nurse mentions a 10% increased risk for individuals with Type A blood, which aligns with the known epidemiological data.
Choice B: Type AB is incorrect because individuals with Type AB blood do not have a known increased risk of gastric cancer.
Choice C: Type B is incorrect because individuals with Type B blood do not have a known increased risk of gastric cancer.
Choice D: Type O is incorrect because individuals with Type O blood actually have a slightly lower risk of developing gastric cancer compared to individuals with Type A blood.
Which laboratory study is monitored for the patient receiving heparin therapy?
- A. INR
- B. PTT
- C. PT
- D. Bleeding time
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect.
A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin.
C: PT (Prothrombin Time) is also used to monitor warfarin therapy.
D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
A 19-year-old student develops symptoms of respiratory alkalosis related to an anxiety attack. Which nursing intervention is appropriate?
- A. Make sure his oxygen is being administered as ordered.
- B. Have him breathe into a paper bag.
- C. Place him in a semi-fowler’s position.
- D. Have him do coughing and deep breathing exercises.
Correct Answer: B
Rationale: The correct answer is B: Have him breathe into a paper bag. Breathing into a paper bag helps increase the carbon dioxide levels in the blood, which can help reverse respiratory alkalosis caused by hyperventilation during an anxiety attack. This intervention helps to normalize the blood pH and alleviate symptoms.
Incorrect choices:
A: Making sure oxygen is administered as ordered is not appropriate for respiratory alkalosis due to hyperventilation. Oxygen therapy can worsen the condition by further reducing carbon dioxide levels.
C: Placing the student in a semi-fowler's position does not directly address the primary issue of respiratory alkalosis and anxiety-induced hyperventilation.
D: Coughing and deep breathing exercises may exacerbate the hyperventilation and worsen the respiratory alkalosis rather than alleviate the symptoms.
A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because:
A: Nurse's concerns are not the primary focus of a nursing health history.
C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care.
D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.