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A client is admitted for postoperative assessment and recovery after surgery for a kidney tumor. The nurse needs to assess for signs of urinary tract infection. Which of the ff measures can be used to help detect UTI?
- A. Encourage the client to breathe deeply and cough every 2hrs
- B. Monitor temperature every 4hrs
- C. Splint the incision when repositioning the client
- D. Irrigate tubes as ordered CARING FOR CLIENTS WITH DISORDERS OF THE BLADDER AND URETHRA
Correct Answer: B
Rationale: The correct answer is B: Monitor temperature every 4hrs. This is crucial in detecting signs of urinary tract infection as fever is a common symptom. Monitoring temperature regularly allows for early detection and appropriate intervention.
A: Encouraging the client to breathe deeply and cough every 2hrs is a measure to prevent respiratory complications postoperatively, not related to UTI detection.
C: Splinting the incision when repositioning the client is important for wound care, not for detecting UTI.
D: Irrigating tubes as ordered is a specific intervention for tube care, not for monitoring UTI symptoms.
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The primary underlying disorder of pulmonary edema is:
- A. Decreased left ventricular pumping
- B. Increased left atrial contractility
- C. Decreased right ventricular elasticity
- D. Increased right atrial pressure
Correct Answer: A
Rationale: Step 1: Pulmonary edema is caused by fluid accumulation in the lungs due to increased pressure in the pulmonary vasculature.
Step 2: Decreased left ventricular pumping leads to congestive heart failure, causing increased pressure in pulmonary circulation.
Step 3: This increased pressure forces fluid from the capillaries into the alveoli, causing pulmonary edema.
Step 4: Increased left atrial contractility (B) would not directly lead to pulmonary edema.
Step 5: Decreased right ventricular elasticity (C) and increased right atrial pressure (D) are not directly related to the pathophysiology of pulmonary edema.
Summary: The correct answer is A because decreased left ventricular pumping directly contributes to the increased pressure in the pulmonary circulation that leads to pulmonary edema. Choices B, C, and D do not align with the primary underlying disorder of pulmonary edema.
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. Reproductive tract
- C. Colon
- D. White blood cells (WBCs)
Correct Answer: A
Rationale: The correct answer is A: Liver. The liver is a common site for metastasis because it receives blood from various organs, making it a prime location for cancer cells to travel and establish secondary tumors. Additionally, the liver has a rich blood supply and provides a favorable environment for cancer cells to thrive. In contrast, B (Reproductive tract) and C (Colon) are not as common sites for metastasis compared to the liver. Choice D (White blood cells) is incorrect as metastasis involves the spread of cancer cells to distant organs, not within the blood cells themselves.
The adrenal cortex is responsible for producing which substances?
- A. Glucocortocoids and androgens
- B. Mineralocortiroids and
- C. Catecholamines and epinephrine catecholamines
- D. Norepinephine and epinephrine
Correct Answer: A
Rationale: The correct answer is A: Glucocorticoids and androgens. The adrenal cortex is divided into three layers, with the outer layer responsible for producing mineralocorticoids like aldosterone, the middle layer producing glucocorticoids like cortisol, and the inner layer producing androgens. Glucocorticoids are essential for regulating metabolism and immune response, while androgens are male sex hormones. Choices B, C, and D are incorrect because mineralocorticoids, catecholamines, norepinephrine, and epinephrine are produced by different parts of the adrenal gland, not specifically by the adrenal cortex.
Which action indicates the nurse is using a PICOT question to improve care for a patient?
- A. Practices nursing based on the evidence presented in court
- B. Implements interventions based on scientific research
- C. Uses standardized care plans for all patients. NursingStoreRN
- D. Plans care based on tradition
Correct Answer: B
Rationale: The correct answer is B because using a PICOT question involves formulating a research question to guide evidence-based practice. B indicates the nurse is implementing interventions based on scientific research, aligning with the PICOT framework (Patient, Intervention, Comparison, Outcome, Timeframe). This approach ensures that care decisions are supported by the best available evidence, leading to improved patient outcomes.
Choice A is incorrect because practicing nursing based on court evidence does not align with the PICOT framework. Choice C is incorrect as using standardized care plans for all patients may not consider individual patient needs and preferences as required in a PICOT question. Choice D is incorrect as planning care based on tradition does not involve integrating current research evidence as in the PICOT approach.
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.