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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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At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
- A. Smoking
- B. Heavy alcohol consumption
- C. Obesity
- D. Saccharin consumption
Correct Answer: C
Rationale: The correct answer is C: Obesity. Obesity is a known risk factor for colon cancer as it can lead to chronic inflammation and changes in hormone levels, increasing the risk of developing cancerous cells in the colon. Smoking (choice A) is more strongly associated with lung cancer. Heavy alcohol consumption (choice B) is linked to increased risk of liver and esophageal cancer, not colon cancer. Saccharin consumption (choice D) has not been definitively linked to colon cancer. In summary, obesity is the most relevant risk factor for colon cancer among the choices provided.
The nurse should include in the patient’s teaching plan that if the patient does not take the vitamin B12, which one of the following will develop?
- A. Iron deficiency anemia
- B. Sickle cell anemia
- C. Pernicious anemia
- D. Acquired haemolytic anemia
Correct Answer: C
Rationale: The correct answer is C: Pernicious anemia. Vitamin B12 is essential for the production of red blood cells, and its deficiency can lead to pernicious anemia, characterized by decreased red blood cell production. Without adequate vitamin B12, the body cannot properly utilize iron, leading to anemia. Iron deficiency anemia (choice A) is a result of insufficient iron levels, not vitamin B12 deficiency. Sickle cell anemia (choice B) is a genetic disorder affecting hemoglobin, not related to vitamin B12 deficiency. Acquired haemolytic anemia (choice D) is caused by the premature destruction of red blood cells, not by vitamin B12 deficiency.
A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will cause the nurse manager to intervene?
- A. Wandering
- B. Hemorrhage NursingStoreRN
- C. Urinary retention
- D. Impaired swallowing
Correct Answer: B
Rationale: The correct answer is B: Hemorrhage. The nurse manager would intervene because hemorrhage is a life-threatening condition requiring immediate attention. Wandering (A), urinary retention (C), and impaired swallowing (D) are important assessments but do not pose the same level of immediate risk as hemorrhage. The nurse manager would prioritize addressing the hemorrhage to ensure the patient's safety and well-being.
Which of the following examples of client data needs to be validated?
- A. A client has trouble reading an informed consent, but states he does not need glasses.
- B. An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
- C. A nurse examining a client with a respiratory infection documents fever and chills.
- D. A client in a nursing home states that she is unable to eat the food being served.
Correct Answer: A
Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight.
- Choice B is about interpreting physical signs, not client data validation.
- Choice C involves documenting objective findings, not validating client information.
- Choice D pertains to a client's complaint, not necessarily requiring validation.
20-year old Mr. Ang fell off from his horse, and sustained a lft hip fracture. Buck’s extension traction is applied. The following statements are true about Buck’s extension traction except:
- A. used as a temporary measure in adults to control muscle spasm and pain
- B. applied by orthopedic surgeon under aseptic conditions using wires and pins
- C. The pulling force is transmitted to the musculoskeletal structures
- D. used definitively to treat fractures in children
Correct Answer: D
Rationale: The correct answer is D because Buck's extension traction is not used definitively to treat fractures in children due to their growing bones. Instead, it is used temporarily in adults to control muscle spasm and pain.
- A: Correct - Buck's extension traction is indeed used temporarily in adults to control muscle spasm and pain.
- B: Correct - Buck's extension traction is applied by an orthopedic surgeon under aseptic conditions using wires and pins.
- C: Correct - The pulling force in Buck's extension traction is indeed transmitted to the musculoskeletal structures.
Therefore, the incorrect option is D as Buck's extension traction is not used definitively to treat fractures in children.