A nurse is caring for a patient with pyelonephritis. What does the nurse identify as the most common cause?
- A. Escherichia coli
- B. Neisseria gonorrhoeae
- C. Chlamydia trachomatis
- D. Candida albicans
Correct Answer: A
Rationale: The correct answer is A: Escherichia coli. Step 1: E. coli is the most common causative agent of pyelonephritis due to its ability to ascend from the lower urinary tract to the kidneys. Step 2: E. coli is a common bacteria found in the gut and can easily infect the urinary tract. Step 3: Neisseria gonorrhoeae, Chlamydia trachomatis, and Candida albicans are not commonly associated with pyelonephritis. Thus, the correct choice is A.
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In which step of the nursing process does the nurse determine the appropriate interventions for the identified nursing diagnosis?
- A. Planning
- B. Evaluation
- C. Assessment
- D. Intervention
Correct Answer: A
Rationale: In the nursing process, planning is the step where the nurse determines the appropriate interventions for the identified nursing diagnosis. Firstly, after assessing the patient's needs (Assessment), the nurse analyzes the data to identify nursing diagnoses. Next, in the Planning step, the nurse sets goals, establishes priorities, and decides on specific interventions to address the nursing diagnoses. This step involves developing a comprehensive care plan tailored to the individual patient's needs. Evaluation comes after the interventions are implemented to assess the effectiveness of the care provided. The Intervention step involves carrying out the planned interventions. Thus, the correct answer is A: Planning.
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previWhich of the following actions should the nurse plan to take?
- A. Initiate continuous monitoring of the FHR.
- B. Administer a dose of betamethasone.
- C. Check the cervix for dilation every 8 hr.
- D. Request that the provider prescribe misoprostol PRN.
Correct Answer: A
Rationale: Continuous fetal heart rate monitoring is essential in placenta previa to assess for fetal distress.
Through the use of social media technology, nurses can link with other nurses who may share similar interests, insights about practice, and advocate for clients. Which factor is the most concerning pitfall for nurses using this technology?
- A. Violation of client privacy and confidentiality
- B. Institutions and colleagues who may be cast in an unfavorable light
- C. Unintended negative consequences for using social media
- D. Lack of institutional policy governing online contact
Correct Answer: A
Rationale: The most significant pitfall is the violation of client privacy and confidentiality.
To provide culturally competent care to an Asian-American family, which question should the nurse include during the assessment interview?
- A. Do you prefer hot or cold beverages?
- B. Do you want some milk to drink?
- C. Do you want music playing while you are in labor?
- D. Do you have a name selected for the baby?
Correct Answer: A
Rationale: Asian-American families may have cultural preferences for warm beverages, especially during labor and delivery. Offering milk may be inappropriate as many in this group exclude milk from their diet. Silence is preferred during labor, and baby naming may be delayed in some traditions.
The most conservative approach for early breast cancer treatment involves lumpectomy followed by which procedure?
- A. Radiation
- B. Adjuvant systemic therapy
- C. Hormonal therapy
- D. Chemotherapy
Correct Answer: A
Rationale: Radiation therapy is typically used after lumpectomy to treat early-stage breast cancer.