Nokea
A client with chronic renal failure is receiving erythropoietin (Epogen). The nurse should monitor the client for which of the following side effects?
- A. Hypertension
- B. Hypoglycemia
- C. Hyperkalemia
- D. Hypocalcemia
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Erythropoietin can lead to hypertension as a side effect due to its stimulation of red blood cell production, which can increase blood viscosity. This can result in elevated blood pressure. Choices B, C, and D are incorrect. Hypoglycemia is not a common side effect of erythropoietin. Hyperkalemia is more commonly associated with renal failure rather than erythropoietin use. Hypocalcemia is not a typical side effect of erythropoietin administration.
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The following statements pertain to devolution as mandated by the local government code. Which of these is not correct?
- A. People can participate in policymaking relative to healthcare delivery.
- B. Devolution will enhance the quality of community life.
- C. The barangay shall set criteria as to who shall be given priority in the delivery of healthcare services.
- D. The DOH shall transfer regulatory function of inspecting food establishments to local government units.
Correct Answer: D
Rationale: The correct answer is D. The Department of Health (DOH) retains regulatory functions for inspecting food establishments, and it is not transferred to local government units. Choices A, B, and C are correct because devolution allows people to participate in policymaking for healthcare, enhances community life quality, and empowers the barangay to set criteria for healthcare service prioritization.
After accepting the position of school nurse in a public elementary school, what strategy is best for the nurse to use to obtain an overview understanding of the student body?
- A. Review all health records of the students currently enrolled in classes.
- B. Talk with the current members of the parent-teacher association.
- C. Send a survey form to parents of third-grade students.
- D. Conduct a windshield survey of the geographic areas served by the school.
Correct Answer: D
Rationale: Conducting a windshield survey is the best strategy for the nurse to obtain an overview understanding of the student body. This method allows the nurse to observe the community, its resources, potential health hazards, and demographic information. Reviewing health records (Choice A) would provide detailed health information but not an overview of the student body. Talking with the parent-teacher association (Choice B) may offer insights but not a comprehensive overview. Sending a survey form to parents (Choice C) may provide specific information but may not capture a broad understanding of the student body.
The RN is making a home visit to a female client with end-stage heart disease. She has a living will and states she will never go back to the hospital. During the visit, the RN notes that the client is pale and SOB while speaking. The RN discovers 3+ edema in both ankles and bilateral pulmonary crackles. Which intervention should the RN implement first?
- A. Order a chest X-ray
- B. Obtain a peripheral O2 saturation reading
- C. Obtain an order for complete blood count
- D. Tell the patient to stay in bed
Correct Answer: B
Rationale: Obtaining a peripheral O2 saturation reading is the priority intervention in this scenario. It helps assess the client's oxygenation status quickly, which is crucial in a client with signs of respiratory distress, such as shortness of breath and bilateral pulmonary crackles. Ordering a chest X-ray (Choice A) may be necessary later but does not address the immediate need for oxygen assessment. Obtaining an order for a complete blood count (Choice C) is not the priority in this situation as it does not directly address the client's respiratory distress. Instructing the patient to stay in bed (Choice D) does not address the underlying issue of potential hypoxia and respiratory compromise.
The nurse manager has a nurse employee who is suspected of having a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
- A. Confront the nurse about the suspicions in a private meeting
- B. Schedule a staff conference, without the nurse present
- C. Consult the human resources department about the issue and needed actions
- D. Counsel the employee to resign to avoid investigation
Correct Answer: C
Rationale: Consulting with human resources is the best approach in this situation. It ensures that the issue is handled according to the organization's policies and that the nurse receives the appropriate support and intervention needed for chemical dependency. Confronting the nurse directly may lead to defensiveness and hinder a constructive resolution. Scheduling a staff conference without the nurse present can create unnecessary speculation and violate the employee's privacy. Counseling the employee to resign is not appropriate and does not address the underlying problem of chemical dependency.
When assessing a child with acute respiratory infection, what nursing intervention(s) would be appropriate?
- A. Provide safe remedies to relieve the child's sore throat and cough
- B. All of these interventions
- C. Advise the mother to monitor for signs of pneumonia
- D. Ensure proper nutrition to prevent weight loss
Correct Answer: B
Rationale: In the management of acute respiratory infection in a child, it is essential to address various aspects of care. Providing safe remedies to relieve symptoms like sore throat and cough (Choice A) helps in managing discomfort. Advising the mother to monitor for signs of pneumonia (Choice C) is crucial for early detection and intervention if complications arise. Ensuring proper nutrition (Choice D) is important for the child's overall health and immune function during illness. Therefore, all the listed interventions are appropriate in managing acute respiratory infection, making Choice B the correct answer. Choices A, C, and D are incorrect on their own as they address only specific aspects of care and not the comprehensive management of acute respiratory infection.