Nokea
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
- A. Helping the client cope with body image
- B. Maintaining a patent airway.
- C. Preventing injury.
- D. Ensuring adequate nutrition.
Correct Answer: B
Rationale: The correct answer is B: Maintaining a patent airway. This is the highest priority because the client with esophageal cancer is at risk for airway obstruction due to difficulty swallowing. Maintaining a patent airway ensures adequate oxygenation and ventilation, which are vital for the client's survival. Without a clear airway, the client may experience respiratory distress or failure. Body image, preventing injury, and ensuring adequate nutrition are important aspects of care but do not take precedence over maintaining a patent airway in this situation.
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The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
- A. Weights every day .
- B. Blood pressure every 15 minutes
- C. Urinary output every hour
- D. Extent of peripheral edema every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.
Which patient would benefit most from a capped IV catheter that is used intermittently rather than continuously?
- A. The patient with pneumonia who needs fluids and antibiotics.
- B. The patient who has had major blood loss after a motor vehicle accident.
- C. The young child who is dehydrated.
- D. The elderly patient who is receiving a diuretic for fluid overload.
Correct Answer: D
Rationale: The correct answer is D, the elderly patient receiving a diuretic for fluid overload. This patient would benefit most from a capped IV catheter used intermittently because diuretics can lead to fluctuations in fluid balance that require careful monitoring and adjustment of IV fluids. By using the catheter intermittently, healthcare providers can better control the amount of fluid administered to prevent electrolyte imbalances.
Option A is incorrect because a patient with pneumonia requiring fluids and antibiotics would likely benefit from a continuous IV to maintain stable levels of medications and hydration. Option B is incorrect as a patient with major blood loss would require continuous IV fluids to restore blood volume. Option C is incorrect as a dehydrated young child would also benefit from continuous IV fluids to rehydrate effectively.
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
- A. Yearly after age 40
- B. After the birth of the first child and every 2 years thereafter
- C. After the first menstrual period and annually thereafter
- D. Every 3 years between ages 20 and 40 and annually thereafter
Correct Answer: A
Rationale: The correct answer is A: Yearly after age 40. This recommendation aligns with the American Cancer Society guidelines that suggest women should start getting annual mammograms at age 40. This age is important as it is when the risk of breast cancer increases. Yearly screenings help in early detection and better treatment outcomes. The other choices (B, C, D) are incorrect because they do not follow the ACS guidelines. Option B is incorrect as it does not specify an age for starting mammograms. Option C is incorrect as it suggests starting after the first menstrual period, which might be too early. Option D is incorrect as it recommends screenings every 3 years between ages 20 and 40, which is not in line with the ACS recommendation for yearly screenings after age 40.
A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
- A. patients.” “If the nursing department uses this system, communication among nurses who work
- B. throughout the hospital may be enhanced.” “We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our
- C. unit.” “The NIC system provides one way to improve safe and effective documentation in the
- D. hospital’s electronic health record.”
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.
What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?
- A. Avoid showering for 1 week.
- B. Sleep in a semi-fowler’s position.
- C. Receive vaccines against infection.
- D. Stay on antibiotics for life.
Correct Answer: C
Rationale: The correct answer is C: Receive vaccines against infection. Following a splenectomy, the patient is at an increased risk of infection due to the absence of the spleen's immune function. Vaccines help boost the body's immunity against specific pathogens, reducing the risk of infections. This is crucial for preventing post-splenectomy infections.
Now, let's analyze the other choices:
A: Avoid showering for 1 week - There is no evidence to support that avoiding showering would prevent infection after a splenectomy.
B: Sleep in a semi-fowler’s position - Positioning does not directly impact infection prevention post-splenectomy.
D: Stay on antibiotics for life - Long-term antibiotic use can lead to antibiotic resistance and is not recommended unless specifically indicated for a different reason.