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A nurse adds a nursing diagnosis to a patient’s care plan. Which information did the nurse document?
- A. Decreased cardiac output related to altered myocardial contractility.
- B. Patient needs a low-fat diet related to inadequate heart perfusion. NursingStoreRN
- C. Offer a low-fat diet because of heart problems.
- D. Acute heart pain related to discomfort.
Correct Answer: A
Rationale: The correct answer is A because it follows the correct format of a nursing diagnosis: "Problem related to Etiology." In this case, "Decreased cardiac output" is the problem, and "altered myocardial contractility" is the cause. This format helps identify the specific issue and its underlying cause, allowing for targeted interventions. Choice B is incorrect as it doesn't follow the problem-etiology format and lacks specificity. Choice C is also incorrect as it lacks a clear nursing diagnosis and specific etiology. Choice D is incorrect as it presents a symptom rather than a nursing diagnosis with an associated cause. Overall, choice A is the best option as it provides a clear, specific nursing diagnosis that guides appropriate nursing interventions.
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The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the ff. interventions is most important for the nurse to do before the procedure?
- A. Explain the procedure to the patient’s family
- B. Observe the patient for bleeding
- C. Administer an analgesic to the patient
- D. Drape the biopsy site
Correct Answer: B
Rationale: The correct answer is B: Observe the patient for bleeding. Before a bone marrow biopsy, it is crucial to monitor the patient for bleeding tendencies as the procedure can cause bleeding. This step ensures early detection and prompt intervention if bleeding occurs.
Explanation for other choices:
A: Explaining the procedure to the family is important for informed consent but not the most crucial before the procedure.
C: Administering an analgesic may be necessary for pain management but monitoring for bleeding takes precedence.
D: Draping the biopsy site is important for maintaining a sterile field but does not directly impact patient safety like monitoring for bleeding.
Which of the following is disease process characterized by a chronic progressive inflammation of the sacroiliac and costovertebral joints and adjacent soft tissue?
- A. Rheumatoid arthritis
- B. Scoliosis
- C. Kyphosis
- D. Ankylosing spondylitis
Correct Answer: D
Rationale: The correct answer is D: Ankylosing spondylitis. This disease process is characterized by chronic progressive inflammation of the sacroiliac and costovertebral joints and adjacent soft tissue. Ankylosing spondylitis specifically affects the spine and large joints. Rheumatoid arthritis (A) is characterized by joint inflammation and primarily affects small joints. Scoliosis (B) is a condition characterized by an abnormal lateral curvature of the spine, not inflammation of the sacroiliac and costovertebral joints. Kyphosis (C) is an excessive outward curvature of the spine, not related to inflammation of the sacroiliac and costovertebral joints.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. First, the nurse needs to assess the severity of the latex allergy to determine the appropriate interventions. Understanding the type of reaction can help guide treatment and prevent future exposure. Isolating the patient (choice A) is not necessary unless there is a severe reaction. Terminating the interview (choice C) prematurely is not appropriate as crucial information may be missed. Documenting the allergy (choice D) is important but not as urgent as assessing the reaction type.
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it is essential to assess the severity of the latex allergy to determine the appropriate precautions and interventions. By asking the patient to describe the type of reaction, the nurse can gather crucial information to ensure patient safety.
Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview prematurely is not appropriate without gathering important information about the allergy. Choice D is incorrect because documenting the allergy is important, but assessing the type of reaction should be the initial priority.
In which of the ff circumstances should a nurse avoid using midline and mid clavicular sites for IV therapy? Choose all that apply.
- A. To administer solutions with a pH greater than 5 and less than 9
- B. To administer antineoplastic chemotherapy
- C. To administer slow, low-volume infusions
- D. To administer high-pressure bolus injections
Correct Answer: B
Rationale: The correct answer is B: To administer antineoplastic chemotherapy. This is because antineoplastic chemotherapy agents are highly irritating and toxic to the surrounding tissues. Using midline and mid clavicular sites for IV therapy in this case can increase the risk of extravasation, leading to tissue damage and potential complications.
Incorrect choices:
A: To administer solutions with a pH greater than 5 and less than 9 - pH of the solution does not directly affect the choice of site for IV therapy.
C: To administer slow, low-volume infusions - Midline and mid clavicular sites can be appropriate for slow, low-volume infusions.
D: To administer high-pressure bolus injections - While midline and mid clavicular sites may not be ideal for high-pressure bolus injections, the question specifically mentions IV therapy, not bolus injections.