Nokea
A hospitalized client has the following blood lab values: WBC 3,000/ul, RBC 5.0 (X 106), platelets 300, 000, what would be a priority nursing intervention?
- A. Preventing infection
- B. Alleviating pain
- C. Controlling infection
- D. Monitoring blood transfusion reactions
Correct Answer: A
Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.
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Which of the following best defines the process of evaluating a nursing intervention?
- A. Collecting data to determine if goals were achieved
- B. Identifying nursing diagnoses for new problems
- C. Adjusting the care plan to include collaborative interventions
- D. Performing client care tasks as per protocol
Correct Answer: A
Rationale: The correct answer is A because evaluating a nursing intervention involves collecting data to determine if the goals set for the intervention were achieved. This process helps in assessing the effectiveness of the intervention in meeting the desired outcomes.
Option B is incorrect as it refers to the identification of nursing diagnoses for new problems, which is part of the nursing assessment phase, not evaluation. Option C is incorrect as adjusting the care plan to include collaborative interventions is part of the implementation phase, not evaluation. Option D is incorrect as performing client care tasks as per protocol is part of the implementation phase, not evaluation.
A client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?
- A. Surgery
- B. Radiation
- C. Chemotherapy
- D. Immunotherapy
Correct Answer: A
Rationale: The correct answer is A: Surgery. Surgery is the primary treatment for vaginal cancer, especially for early-stage cases. It involves removing the cancerous tissue from the vagina. Radiation (B) and chemotherapy (C) may also be used in addition to surgery in some cases, but they are not the primary treatment. Immunotherapy (D) is not a standard treatment for vaginal cancer. It is important to prioritize surgery as it directly targets and removes the cancerous cells from the affected area, increasing the chances of successful treatment and recovery.
Which of the following is a nurse patient care role in the preoperative phase?
- A. Obtaining preoperative orders
- B. Offering emotional support
- C. Explaining the surgical procedure
- D. Providing informed consent
Correct Answer: B
Rationale: The correct answer is B: Offering emotional support. In the preoperative phase, a nurse's role includes comforting and reassuring the patient to reduce anxiety and promote emotional well-being. This is crucial for the patient's overall experience and can positively impact their recovery. Obtaining preoperative orders (A) is typically the responsibility of the physician. Explaining the surgical procedure (C) is usually done by the surgeon. Providing informed consent (D) involves ensuring the patient understands the risks and benefits of the procedure, which is typically the responsibility of the healthcare provider performing the procedure.
What is the nurse’s firstaction?
- A. Follow the clinical protocol for a stroke.
- B. Review the most recent lab results for the patient’s potassium level. Assess the patient for other symptoms or problems, and then notify the health care
- C. provider. Administer an antihypertensive medication from the stock supply, and then notify the
- D. health care provider.
Correct Answer: B
Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.
What is the first action the nurse should take?
- A. Start an IV lines for fluids
- B. Get an ECG
- C. Place a Foley catheter
- D. Check for neurologic status
Correct Answer: D
Rationale: The correct answer is D: Check for neurologic status. This is the first action because assessing the patient's neurologic status helps identify any immediate threats to their health and guides further interventions. It is crucial to ensure the patient's safety and prioritize interventions based on their neurologic status. Starting an IV for fluids (A), getting an ECG (B), and placing a Foley catheter (C) are important interventions but should come after assessing the patient's neurologic status to address any urgent issues first.