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A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?
- A. Patient will increase activity level this shift.
- B. Patient will turn side to back to side with assistance every 2 hours.
- C. Patient will use the walker correctly to ambulate to the bathroom as needed.
- D. Patient will use a sliding board correctly to transfer to the bedside commode as needed.
Correct Answer: C
Rationale: The correct answer is C because it is a realistic goal for a patient with a pelvic fracture on bed rest. The patient needs to use a walker correctly to ambulate safely to the bathroom, which promotes mobility and independence while ensuring safety. This goal is specific, measurable, achievable, relevant, and time-bound.
Choice A is incorrect because increasing activity level may not be safe or feasible for a patient with a pelvic fracture. Choice B is incorrect as turning every 2 hours may not be necessary or practical for this patient. Choice D is incorrect as using a sliding board may not be appropriate or necessary for someone with a pelvic fracture.
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A nurse is directed to administer a hypotonic intravenous solution. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. O.45% sodium chloride
- B. 5% dextrose in water
- C. O.90% sodium chloride
- D. 5% dextrose in normal saline solution
Correct Answer: C
Rationale: The correct answer is C: 0.90% sodium chloride. When administering a hypotonic solution like 0.45% sodium chloride or 5% dextrose in water, water moves into the cells causing them to swell. This can exacerbate symptoms of hypovolemia such as low blood pressure and decreased perfusion. However, 0.90% sodium chloride is an isotonic solution and will not further exacerbate hypovolemic symptoms. Choices A, B, and D are hypotonic solutions that can worsen hypovolemic symptoms by causing cellular swelling.
Which of the following parts of neuron transmits impulses away from the cell body?
- A. Dendrite
- B. . Neurolemma
- C. Axon
- D. Synapse
Correct Answer: C
Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons, muscles, or glands. Its structure allows for the rapid transmission of electrical signals.
Rationale:
1. Dendrites receive signals and transmit them towards the cell body, so A is incorrect.
2. Neurolemma is the outermost layer of a Schwann cell, not a part of the neuron responsible for transmitting impulses, so B is incorrect.
3. The synapse is the junction between two neurons where communication occurs, not a part of the neuron transmitting impulses, so D is incorrect.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C: The patient is apprehensive about discharge. The rationale is that the patient's fear of going home and being alone indicates anxiety about leaving the hospital setting. This subjective data suggests that the patient may not feel ready for discharge despite stable vital signs and nearly healed incision. Choices A and B are incorrect because they assume the patient's readiness for self-care without considering emotional factors. Choice D is incorrect as there is no evidence provided that the surgery was unsuccessful.
A patient is being given Digoxin to treat heart failure. Which of the ff. is a usual adult daily dosage of digoxin (Lanoxin)?
- A. 0.005 mg
- B. 0.025 mg
- C. 0.25 mg
- D. 2.5 mg
Correct Answer: C
Rationale: Rationale:
C: 0.25 mg is the correct daily dosage of Digoxin for adults with heart failure. This dosage is within the usual range of 0.125-0.25 mg. It helps improve heart function and manage heart failure symptoms.
A: 0.005 mg is too low and ineffective.
B: 0.025 mg is also too low for therapeutic effect.
D: 2.5 mg is too high and may lead to toxicity in most adult patients.
The presence of anemia is characterized by a/an:
- A. Increase of red blood cells
- B. Increased hemoglobin
- C. Decrease in the concentration of red blood
- D. Decreased blood count cells
Correct Answer: C
Rationale: Step-by-step rationale:
1. Anemia is a condition where there is a decrease in the concentration of red blood cells.
2. Red blood cells carry oxygen to the body's tissues, so a decrease in their concentration leads to reduced oxygen delivery.
3. This decrease in red blood cell concentration can be measured through a decrease in hematocrit levels.
4. Choices A and B are incorrect because anemia involves a decrease, not an increase, in red blood cells and hemoglobin.
5. Choice D is incorrect as it mentions "decreased blood count cells," which is not a specific term related to anemia.
Summary: The correct answer is C because anemia is characterized by a decrease in the concentration of red blood cells, leading to reduced oxygen delivery, while the other choices are incorrect due to inaccuracies in describing anemia.