Nokea
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
- A. lubricate the walls of the intestinal tract
- B. soften the fecal mass and lubricate the walls of the rectum and colon
- C. reduce bacterial content of the fecal mass
- D. coat the walls of the intestines to prevent irritation by the hardened fecal mass
Correct Answer: B
Rationale: The correct answer is B: soften the fecal mass and lubricate the walls of the rectum and colon. First, the oil retention enema helps soften the fecal mass, making it easier to pass. Second, the oil lubricates the walls of the rectum and colon, reducing friction and making the passage of stool smoother. This helps prepare the fecal impaction for removal during the subsequent cleansing enema. Choices A, C, and D are incorrect because they do not directly address the primary goal of softening the fecal mass and lubricating the walls of the intestines to facilitate the removal of the impaction.
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Which of the ff is the main reason why older clients with AIDS need more care than their younger counterparts?
- A. Because the older clients lack balanced diet and activity
- B. Because older clients lack knowledge about disorders
- C. Because older clients have a faster progression of disease
- D. Because older clients do not generally adhere to a therapy
Correct Answer: C
Rationale: The correct answer is C because older clients with AIDS have a faster progression of the disease due to age-related changes in the immune system, making them more vulnerable to complications. This results in a greater need for care compared to younger counterparts. Choice A is incorrect as lack of balanced diet and activity does not directly relate to the progression of AIDS. Choice B is incorrect as knowledge about disorders is not the main factor affecting the level of care needed. Choice D is incorrect as adherence to therapy is important but not the main reason older clients need more care.
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
- A. tachycardia
- B. hyperthermia
- C. weight loss
- D. extreme fatigue
Correct Answer: D
Rationale: The correct answer is D, extreme fatigue, for a patient suspected of having hypothyroidism. Hypothyroidism is associated with decreased production of thyroid hormones, leading to a slower metabolism and reduced energy levels. This results in symptoms such as fatigue, weakness, and lethargy. Tachycardia (A) is more commonly associated with hyperthyroidism, where the thyroid is overactive. Hyperthermia (B) is increased body temperature, not typically a symptom of hypothyroidism. Weight loss (C) is also more commonly seen in hyperthyroidism due to increased metabolism. In summary, extreme fatigue is a hallmark symptom of hypothyroidism due to decreased thyroid hormone levels, distinguishing it from the other choices.
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment?
- A. Carrying out a physician’s order to intubate a client
- B. Educating a novice nurse on the principles of triage
- C. Using the nursing process to diagnose a blocked airway
- D. Interviewing privately a client suspected of being a victim of abuse
Correct Answer: D
Rationale: The correct answer is D because interviewing a client suspected of being a victim of abuse involves critical thinking in assessment by gathering relevant information, analyzing the situation, and making informed decisions. This activity helps identify potential risks and ensures the client's safety. On the other hand, options A and C involve implementing orders and diagnosing conditions, respectively, which are more related to clinical decision-making rather than assessment. Option B focuses on education, which is not directly linked to assessment activities.
The nurse evaluates that furosemide IV is effective in treating pulmonary edema if which of the following patient signs or symptoms is resolved?
- A. Pedal edema
- B. Pink, frothy sputum
- C. Jugular vein distention
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pink, frothy sputum. This is because pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. Furosemide IV is a diuretic that helps remove excess fluid from the body, including the lungs. Resolving pink, frothy sputum indicates that the treatment is effectively reducing the fluid in the lungs.
Incorrect choices:
A: Pedal edema - This refers to swelling in the feet and ankles, which is not directly related to pulmonary edema.
C: Jugular vein distention - This is a sign of heart failure, not specifically pulmonary edema.
D: Bradycardia - This is a slow heart rate and not a direct indicator of pulmonary edema resolution.
While planning for proportionate distribution of restricted fluid volumes, what is the reason for a nurse to ensure that the client is actively involved during the development of the plan?
- A. It promotes the clients compliance with therapy
- B. It minimizes the chances of adverse effects
- C. It promotes a strict food and fluid intake habit
- D. It raises the self esteem of the client
Correct Answer: A
Rationale: Step 1: Involving the client in planning increases their understanding and ownership of the plan.
Step 2: Understanding leads to better compliance with therapy recommendations.
Step 3: Compliance improves outcomes and prevents complications.
Step 4: Thus, choice A is correct. Choices B, C, and D lack direct links to client involvement in planning and compliance.