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A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
- A. The patient will ambulate in hallways.
- B. The nurse will monitor the patient’s heart rhythm continuously this shift. The patient will feed self at all mealtimes today without reports of shortness of
- C. breath. The nurse will administer pain medication every 4 hours to keep the patient free from
- D. discomfort.
Correct Answer: B
Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.
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A patient with a new diagnosis of lung cancer decides to have radiation therapy. Which of the ff. expectations of this treatment is most appropriate?
- A. Complete cure of the cancer
- B. Prevention of the need for oxygen
- C. Increased comfort
- D. Prevention of cancer spread
Correct Answer: C
Rationale: The correct answer is C: Increased comfort. Radiation therapy for lung cancer aims to alleviate symptoms, reduce pain, and improve quality of life. It is not typically used as a curative treatment like surgery or chemotherapy (A). It does not prevent the need for oxygen (B), as lung cancer can still affect lung function. While radiation therapy may help control the growth of cancer cells, it is not always effective in preventing cancer spread (D). Therefore, the most appropriate expectation of radiation therapy for lung cancer is increased comfort for the patient.
A client with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
- A. Vision changes
- B. Headache
- C. Hearing loss
- D. Anorexia
Correct Answer: A
Rationale: The correct answer is A: Vision changes. This is crucial to report immediately because tamoxifen can cause serious eye problems such as retinopathy. Vision changes could indicate a potentially serious adverse reaction that requires prompt medical attention to prevent permanent damage. Headache, hearing loss, and anorexia are not typically associated with tamoxifen use and are less urgent in nature. Reporting vision changes promptly can help prevent irreversible harm and ensure timely intervention.
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
- A. Maintenance of blood glucose levels between 180 and 200mg/dl
- B. Smoking reduction but not complete cessation
- C. An eye examination every 2 years until age 50
- D. Exercise and a weight reduction diet
Correct Answer: D
Rationale: The correct answer is D, as exercise and a weight reduction diet are essential components in managing type 2 diabetes. Exercise helps lower blood glucose levels and improves insulin sensitivity. Weight reduction reduces insulin resistance. Choice A is incorrect because maintaining blood glucose levels between 180-200mg/dl is too high and can lead to complications. Choice B is incorrect as complete smoking cessation is crucial for overall health and diabetes management. Choice C is incorrect because eye examinations should be done annually, not every 2 years, to monitor for diabetic retinopathy. In summary, choice D is the best option as it directly addresses the management of type 2 diabetes.
A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?
- A. Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.
- B. Encourage the novice nurse to develop his or her own tool for data collection.
- C. Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation.
- D. Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.
Correct Answer: A
Rationale: The correct answer is A because it encourages the novice nurse to independently observe the situation with a peer, validate the data, and discuss afterward. This approach promotes reflection, peer learning, and validation of collected data, which are essential for learning and growth. It allows the nurse to self-assess and correct errors through discussion and feedback.
Choice B is incorrect as it does not address the need for validation and peer feedback. Choice C is incorrect as repeating the same mistake without guidance does not promote learning. Choice D is incorrect as meeting with the nurse manager may not provide the same level of peer learning and validation as observing with a peer.
A client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis site for cancer cells?
- A. Liver
- B. Colon
- C. Reproductive tract
- D. White blood cells (WBCs)
Correct Answer: A
Rationale: The correct answer is A: Liver. Cancer cells commonly metastasize to the liver due to its rich blood supply, making it an ideal environment for tumor growth. Liver metastasis can occur from various primary cancer sites. The liver filters blood and is susceptible to receiving cancer cells circulating in the bloodstream. Metastasis to the colon (B) is less common as it is typically the primary site for colon cancer. Metastasis to the reproductive tract (C) can occur but is not as common as liver metastasis. White blood cells (D) are a part of the immune system and do not serve as a common site for cancer metastasis.