Nokea
A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
- A. Decreased gastrointestinal motility
- B. Pain medication
- C. Abdominal distention
- D. Constipation
Correct Answer: A
Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.
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A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. In a nursing health history, the nurse focuses on understanding the patient's expectations, needs, and preferences to provide patient-centered care. This step is essential for building rapport, establishing trust, and tailoring care plans to meet the patient's individual needs.
Incorrect choices:
A: Nurse’s concerns - This is not the primary focus during a nursing health history. The nurse should prioritize understanding the patient's perspective.
C: Current treatment orders - While important, this is typically addressed during the assessment phase, not specifically in the nursing health history.
D: Nurse’s goals for the patient - The nurse's goals should align with the patient's goals, making understanding the patient's expectations crucial.
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
- A. “Take ferrous sulfate and the antacid together.”
- B. “Take ferrous sulfate and the antacid at least 2 hours apart.”
- C. “Avoid taking an antacid altogether.”
- D. “Take ferrous sulfate and the antacid at least 1 hour apart.”
Correct Answer: B
Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart."
Rationale:
1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity.
2. Antacids can bind to iron and reduce its absorption.
3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid.
4. Taking them together (choice A) would decrease iron absorption.
5. Avoiding antacids altogether (choice C) may not be necessary if spaced apart appropriately.
6. Taking them 1 hour apart (choice D) may still lead to decreased iron absorption due to antacid interference.
Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
- A. “Your urine will be collected in a pouch following surgery.”
- B. “You will have a nasogastric tube after surgery.”
- C. “Your bowel will be visualized with a laparoscope during surgery.”
- D. “You can drink liquids within 24 hours after surgery.”
Correct Answer: A
Rationale: The correct answer is A because an Ileostomy involves diverting the small intestine to an opening in the abdominal wall, so the urine will not be affected. The pouch collects waste from the small intestine. Nasogastric tube (B) is not typically required for an Ileostomy. Laparoscope (C) is used for visualizing the abdomen, not the bowel. Drinking liquids (D) so soon after surgery can be risky and is not recommended.
Which of the ff suggestions should a nurse give breastfeeding mothers to prevent or eliminate mastitis and breast abscess? Choose all that apply
- A. Offer the opposite breast at each feeding to their
- B. Avoid frequent nursing of the infants
- C. Avoid breastfeeding
- D. Ensure that their hands and breasts are clean
Correct Answer: D
Rationale: Rationale:
D is correct because cleanliness helps prevent infections. Washing hands and keeping breasts clean reduces the risk of mastitis and abscesses.
A is incorrect because alternating breasts is a common practice in breastfeeding.
B is incorrect as frequent nursing helps maintain milk supply and prevent engorgement, reducing the risk of mastitis.
C is incorrect as breastfeeding itself is not a cause of mastitis or abscess; stopping abruptly can lead to further complications like engorgement.
How many liters per minute of oxygen should be administered to the patient with emphysema?
- A. 2 L/min
- B. 10 L/min
- C. 6 L/min
- D. 95 L/min
Correct Answer: A
Rationale: The correct answer is A: 2 L/min. In emphysema, there is impaired gas exchange due to damaged lung tissue, resulting in decreased oxygen levels. Administering too high a flow rate can lead to oxygen toxicity. The standard oxygen therapy for emphysema is 1-2 L/min to maintain oxygen saturation without causing harm. Higher flow rates like 10 L/min (B) and 6 L/min (C) are excessive and can lead to oxygen toxicity. 95 L/min (D) is dangerously high and not suitable for oxygen therapy in emphysema. Therefore, A is the correct choice for safe and effective oxygen administration in emphysema.