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A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances.
Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.
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To reduce symptoms of early morning stiffness in a ptient who has rheumatoid arthritis, the nurse can encourage the patient to:
- A. take a hot tub bath or shower in the morning
- B. put joints through passive ROM before tryoing to move them actively
- C. sleep with a hot pad
- D. take two aspirins before arising, and wait 15 minutes before attempting locomotion
Correct Answer: A
Rationale: The correct answer is A: take a hot tub bath or shower in the morning. This is effective as the warm water helps to relax muscles and joints, reducing stiffness. It also improves circulation, which can alleviate morning stiffness in patients with rheumatoid arthritis.
Incorrect choices:
B: Putting joints through passive ROM before active movement may exacerbate stiffness if not done properly.
C: Sleeping with a hot pad may provide temporary relief but does not address the root cause of morning stiffness.
D: Taking aspirin can help with pain but does not directly address stiffness. Waiting 15 minutes before moving may not be as effective as soaking in warm water.
Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
- A. “Data interpretation occurs before data validation.”
- B. “Validation involves looking for patterns in professional standards.”
- C. “Validation involves comparing data with other sources for accuracy.”
- D. “Data interpretation involves discovering patterns in professional standards.”
Correct Answer: C
Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This process helps in identifying any discrepancies or errors in the data. By cross-referencing with other sources, the nurse can verify the correctness of the data.
Rationale:
1. Data validation checks the accuracy of the data by comparing it with external sources.
2. Data interpretation involves analyzing and making sense of the data, not comparing it with other sources.
3. Option A is incorrect because data validation typically comes after data collection and precedes data interpretation.
4. Option B is incorrect as validation does not specifically involve looking for patterns in professional standards.
5. Option D is incorrect because data interpretation focuses on understanding trends and insights from the data, not patterns in professional standards.
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.
Decreasing level of consciousness is a symptom of which of the following physiological phenomena?
- A. Increased ICP
- B. Parasympathetic response
- C. Sympathetic response
- D. Increased cerebral blood flow
Correct Answer: A
Rationale: The correct answer is A: Increased ICP. Decreasing level of consciousness is a classic sign of increased intracranial pressure (ICP) due to the compression of the brain. As ICP rises, it impairs cerebral perfusion leading to altered mental status. Parasympathetic response (B) and sympathetic response (C) are related to autonomic nervous system functions, not consciousness. Increased cerebral blood flow (D) might lead to conditions like hyperemia but does not directly cause a decreased level of consciousness.
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.