Nokea
A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. When adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
- A. Hypertension
- B. Muscle wasting
- C. Osteoporosis
- D. Truncal obesity
Correct Answer: C
Rationale: The correct answer is C: Osteoporosis. Long-term corticosteroid therapy, such as prednisone, is known to cause bone loss and increase the risk of osteoporosis. Corticosteroids inhibit bone formation and increase bone resorption, leading to decreased bone density and increased fracture risk, which can manifest as severe back pain.
Incorrect choices:
A: Hypertension - Corticosteroids can cause fluid retention and sodium retention, leading to hypertension, but it is not typically associated with severe back pain.
B: Muscle wasting - Corticosteroids can lead to muscle weakness, but severe back pain is not typically related to muscle wasting.
D: Truncal obesity - Corticosteroids can cause weight gain, especially in the trunk area, but this is not directly responsible for severe back pain.
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Which of the ff is a nursing intervention when assessing clients with hypertension?
- A. The nurse takes the temperature when the client is in a standing, sitting, and then supine position
- B. The nurses teaches the client about non pharmacologic and pharmacologic methods for restoring BP
- C. The nurse takes BP in both arms when the client is in a standing, sitting, and then supine position
- D. The nurse weighs the client each morning
Correct Answer: B
Rationale: The correct answer is B because teaching the client about both non-pharmacologic and pharmacologic methods for managing hypertension is a crucial nursing intervention to empower the client in their self-care and treatment plan. This intervention helps the client understand the importance of lifestyle modifications and medication adherence in controlling blood pressure.
A: The nurse taking the temperature in different positions is not directly related to assessing hypertension.
C: Taking BP in different positions is important for orthostatic hypotension, not specifically for hypertension.
D: Weighing the client each morning is not a direct nursing intervention for assessing hypertension.
A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)
- A. Order chest x-ray for suspected arm fracture.
- B. Prescribe antibiotics for a wound infection.
- C. Reposition a patient who is on bed rest.
- D. Teach a patient preoperative exercises.
Correct Answer: C
Rationale: Step 1: Repositioning a patient who is on bed rest is a nursing intervention as it involves direct patient care to prevent complications like pressure ulcers.
Step 2: Nursing interventions aim to promote patient health, prevent illness, and provide comfort.
Step 3: Ordering chest x-ray and prescribing antibiotics are medical interventions, beyond the scope of nursing practice.
Step 4: Teaching preoperative exercises falls under nursing education but not a direct nursing intervention involving patient care.
Summary: Choice C is correct as it aligns with the essence of nursing interventions focusing on patient care and wellbeing. Choices A, B, and D involve actions that are not within the scope of nursing interventions.
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
- A. No sputum or cough present in 4 days
- B. Congestion throughout all lung fields in 2 days
- C. Shallow, fast respirations 30 breaths per minute in 1 day
- D. Lungs clear to auscultation following use of inhaler
Correct Answer: D
Rationale: The correct evaluative measure is D: Lungs clear to auscultation following use of inhaler. This choice aligns with the expected outcome of having no secretions present in the lungs in 48 hours. By using an inhaler to clear the lungs, the nurse can assess if the expected outcome is being met. This measure directly evaluates the presence of secretions in the lungs, in line with the established goal.
Incorrect Choices:
A: No sputum or cough present in 4 days - This measure does not align with the expected outcome of having no secretions present in the lungs in 48 hours.
B: Congestion throughout all lung fields in 2 days - This indicates a worsening condition and does not demonstrate progress towards the goal.
C: Shallow, fast respirations 30 breaths per minute in 1 day - This measure is unrelated to the presence of secretions in the lungs and the goal of avoiding shortness of breath with activity.
A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
- A. 13 gtt/min
- B. 29 gtt/min
- C. 16 gtt/min
- D. 32 gtt/min Situation 5: Protection of self and patient can be done by supporting the body's immunity.
Correct Answer: B
Rationale: To calculate the drip rate, we first need to find the total volume of IV fluid to be administered, which is 1500 ml + 1250 ml = 2750 ml. Then, we multiply the total volume by the drop factor (2750 ml * 15 gtt/ml = 41250 gtt). Finally, we divide the total number of drops by the time in minutes (24 hours * 60 min = 1440 min) to get the drip rate: 41250 gtt / 1440 min = 28.47 gtt/min, which rounds up to 29 gtt/min. Therefore, choice B is correct. Choices A, C, and D are incorrect because they do not reflect the accurate calculation based on the given parameters.
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
- A. Where is the pain located?
- B. What causes the pain?
- C. Does it come and go?
- D. What does the pain feel like?
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis.
Explanation of other choices:
B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect.
C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location.
D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,