Nokea
A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?
- A. Decreased subcutaneous fat
- B. Muscle atrophy
- C. Pressure injury
- D. Fecal impaction
Correct Answer: C
Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.
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The caregiver is teaching parents about the diet for a 4-month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. Formula or breast milk
- B. Broth and tea
- C. Rice cereal and apple juice
- D. Gelatin and ginger ale
Correct Answer: A
Rationale: The correct answer is A: Formula or breast milk. In infants with gastroenteritis and mild dehydration, it is essential to continue feeding them with formula or breast milk along with oral rehydration fluids to provide adequate nutrition and maintain hydration. Option B, broth and tea, may not provide the necessary nutrients and electrolytes needed for the infant's recovery. Option C, rice cereal and apple juice, can be harsh on the digestive system and may exacerbate diarrhea. Option D, gelatin and ginger ale, do not provide the necessary nutrients and can worsen the condition due to the high sugar content in ginger ale.
A healthcare professional is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the healthcare professional question?
- A. Oral psyllium (Metamucil)
- B. Oral potassium supplement
- C. Parenteral half normal saline
- D. Parenteral albumin (Albuminar)
Correct Answer: D
Rationale: The correct answer is D, Parenteral albumin (Albuminar). Parenteral albumin is not typically indicated for dehydration resulting from diarrhea. In this case, fluid replacement therapy with intravenous fluids such as parenteral half normal saline would be more appropriate. Oral psyllium and oral potassium supplement are not the primary interventions for managing dehydration due to watery diarrhea. Oral psyllium is a fiber supplement used for constipation rather than diarrhea. Oral potassium supplements may be necessary if potassium levels are low due to dehydration, but the priority is fluid replacement. Therefore, choices A and B are less relevant in this scenario.
While providing care to a group of patients, which patient should the nurse prioritize seeing first?
- A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
- B. A bedridden patient with a reddened area on the buttocks who needs to be turned
- C. A patient on bed rest with renal calculi who needs to go to the bathroom
- D. A patient post-knee surgery who needs range of motion exercises
Correct Answer: A
Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.
A nurse on a med-surg unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?
- A. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions
- B. A client who has a new colostomy refuses to follow instructions from the ostomy therapist because she 'doesn't like him'
- C. The family of a client who has a terminal illness asks that the provider not disclose the diagnosis to the client
- D. A client who has Crohn's disease reports that his prescription drug plan will not cover his medications
Correct Answer: C
Rationale: The correct answer is C. It is an ethical dilemma when the family of a client with a terminal illness asks healthcare providers not to inform the client of their diagnosis. This situation poses a conflict between respecting the client's right to know the truth about their condition (autonomy and truth-telling principles) and honoring the family's wishes. Choices A, B, and D do not present ethical dilemmas. Choice A involves professional accountability and responsibility, Choice B involves a client's personal preference, and Choice D involves financial challenges.
A healthcare provider in an office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the provider expect?
- A. Rhonchi
- B. Crackles
- C. Resonance
- D. Tactile fremitus
Correct Answer: C
Rationale: During a thoracic examination, normal findings should include resonance, which is the expected sound when percussing the thorax. Resonance indicates healthy lung tissue and air-filled spaces. Abnormal findings such as rhonchi and crackles suggest issues like lung congestion or inflammation. Tactile fremitus refers to vibrations felt on the chest wall during palpation and is not typically assessed during percussion and auscultation of the thorax.