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A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
- A. To restore and maintain intravascular volume
- B. To provide a means for further comparison and evaluation
- C. To avoid interference with wound drainage
- D. To prevent pain related to obstruction
Correct Answer: B
Rationale: The correct answer is B: To provide a means for further comparison and evaluation. By recording the color of drainage from each tube and catheter, the nurse can monitor changes over time, assess for any abnormalities, and evaluate the effectiveness of treatment. This helps in detecting complications early and making informed decisions.
Rationale for other choices:
A: To restore and maintain intravascular volume - Monitoring drainage color does not directly relate to intravascular volume status.
C: To avoid interference with wound drainage - Monitoring drainage color does not prevent interference with wound drainage.
D: To prevent pain related to obstruction - Monitoring drainage color does not directly prevent pain related to obstruction.
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During the physical assessment, the nurse recalls that the areas most frequently affected by multiple sclerosis are the:
- A. Lateral, 3rd and 4th ventricles
- B. Pons medulla and cerebral peduncles
- C. Optic nerve and chiasm
- D. Above areas
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer):
1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm.
2. MS is characterized by demyelination of nerves, leading to visual disturbances.
3. Optic nerve involvement results in vision problems, such as blurred vision.
4. Chiasm involvement can cause visual field deficits and color perception changes.
Summary of Other Choices:
A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles.
B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS.
D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.
Which of the following procedures does the nurse understand is used to correct otosclerosis?
- A. Myringotomy
- B. Mastoidectomy
- C. Myringoplasty
- D. Stapedectomy
Correct Answer: D
Rationale: The correct answer is D: Stapedectomy. This procedure is used to correct otosclerosis by removing the stapes bone and replacing it with a prosthetic device. This restores normal hearing by allowing sound waves to travel through the ear properly. Myringotomy (A) is a procedure to drain fluid from the middle ear, not to correct otosclerosis. Mastoidectomy (B) is the removal of infected mastoid air cells, not related to otosclerosis. Myringoplasty (C) is a surgical procedure to repair a perforated eardrum, not used for otosclerosis. Stapedectomy is the most appropriate choice for correcting otosclerosis as it directly addresses the abnormal bone growth in the middle ear.
Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?
- A. Cellular dehydration and potassium
- B. Hypoglycemia and hypovolemia
- C. Potassium excess and CHF
- D. Circulatory overload and hypoglycemia SITUATION: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.
Correct Answer: D
Rationale: Rationale:
1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system.
2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema.
3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution.
Summary:
A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration.
B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect.
C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect.
D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In the scenario, the nurse failed to assess the patient's condition promptly after the patient complained of feeling dizzy and light-headed. Assessment is the first phase of the nursing process and involves collecting data to identify the patient's health status. By not reassessing the patient's vital signs and symptoms, the nurse missed an opportunity to detect the worsening condition. The other choices are incorrect because the error occurred before diagnosis (B), implementation (C), and evaluation (D) phases. In diagnosis, the nurse identifies the patient's problems; in implementation, the nurse carries out the care plan; and in evaluation, the nurse assesses the effectiveness of interventions.
Mr. RR is admitted to the hospital with a diagnosis of brain tumor. Mr. RR’s doctor is very much concerned about the possibility of increased intracranial pressure. The following is the most reliable index of cerebral state:
- A. Level of consciousness
- B. Unilateral papillary dilatation
- C. Increased systolic BP
- D. Decreased pulse pressure
Correct Answer: A
Rationale: Step 1: Level of consciousness is the most reliable index of cerebral state because it directly reflects the functioning of the brain. Changes in consciousness can indicate alterations in cerebral perfusion and potential increases in intracranial pressure.
Step 2: Unilateral papillary dilatation may suggest an increase in intracranial pressure, but it is not as reliable as level of consciousness in assessing overall cerebral state.
Step 3: Increased systolic blood pressure can occur due to various reasons and may not specifically indicate changes in intracranial pressure.
Step 4: Decreased pulse pressure may be related to factors such as hypovolemia or cardiac conditions, but it is not a direct indicator of cerebral state or intracranial pressure.