Nokea
Which of the ff. statements, if made by a patient with hypertension, indicates to a nurse a need for more teaching?
- A. “High BP may affect the kidneys and eyes.”
- B. “Most people with hypertension watch their diet.”
- C. “Medication will no longer be needed when I feel better.”
- D. “Many people do not know when their BP is high.”
Correct Answer: C
Rationale: Step-by-step rationale:
1. Statement C indicates a misunderstanding that medication can be stopped when feeling better, which is incorrect.
2. Hypertension is a chronic condition that often requires lifelong medication.
3. This demonstrates a lack of understanding regarding the necessity of long-term management.
4. Statements A, B, and D show knowledge about hypertension's effects, dietary management, and awareness, respectively.
Summary: Statement C is incorrect as it suggests stopping medication, while statements A, B, and D show accurate understanding of hypertension.
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Which of the ff actions should the nurse perform before a client with impaired physical mobility gets up?
- A. Use parallel bars or a walker
- B. Use incontinence pads
- C. Apply an abdominal binder
- D. Use a footboard
Correct Answer: A
Rationale: The correct answer is A: Use parallel bars or a walker. Before a client with impaired physical mobility gets up, the nurse should provide assistive devices like parallel bars or a walker to ensure safe and supported ambulation. This helps prevent falls and promotes independence. Using incontinence pads (B) is not directly related to mobility. Applying an abdominal binder (C) is not necessary before the client gets up. Using a footboard (D) is more relevant for positioning in bed, not for assisting with ambulation.
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.
Which of the following is an example of a well-stated nursing intervention?
- A. Client will drink 100 mL of water every 2 hours while awake.
- B. Offer client 100 mL of water every 2 hours while awake.
- C. Offer client water when he complains of thirst.
- D. Client will continue to increase oral intake when awake.
Correct Answer: B
Rationale: The correct answer is B because it provides a specific action (offering water) at regular intervals (every 2 hours) to promote hydration, which is a clear and measurable nursing intervention. Choice A is too prescriptive and lacks flexibility. Choice C is reactive and not proactive. Choice D is vague and lacks specific guidance on how to achieve the desired outcome. By offering water consistently, the nurse ensures proactive care and helps meet the client's hydration needs effectively.
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.
Which instruction about insulin administration should the nurse give to a client?
- A. “Always follow the same order when drawing the different insulin into the syringe.”
- B. “Shake the vial before withdrawing the insulin.”
- C. “Store unopened vials of insulin in the freezer at temperatures well below freezing.”
- D. “Discard the intermediate-acting insulin if it disappears cloudy.”
Correct Answer: A
Rationale: The correct answer is A because maintaining consistency in the order of drawing different types of insulin into the syringe helps prevent medication errors. When mixing insulins, drawing them in the same sequence ensures the correct dose and prevents contamination.
Explanation:
A: Following the same order ensures accurate dosing and minimizes the risk of mixing up insulins.
B: Shaking the vial can cause air bubbles which can affect the accuracy of the dose.
C: Storing insulin in the freezer can damage the medication and alter its effectiveness.
D: Cloudiness in intermediate-acting insulin is normal and does not indicate it should be discarded.