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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 client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect. The anesthesiologist should monitor the client for this adverse reaction. Muscle rigidity and spasms are common with ketamine administration and can affect the client's comfort and safety during the procedure. It is important for the nurse to promptly address any signs of muscle rigidity or spasms to prevent complications.
Summary of why other choices are incorrect:
B: Hiccups - Ketamine can cause hiccups, but it is not the primary side effect to monitor for in this scenario.
C: Extrapyramidal reactions - Ketamine does not typically cause extrapyramidal reactions.
D: Respiratory depression - Ketamine is known for its minimal effect on respiratory depression compared to other anesthetics. Monitoring respiratory depression is still important, but not the primary concern with ketamine administration in this case.
A pregnant client requires immediate but temporary protection from chickenpox. Which type of immunization would be required?
- A. Naturally acquired active immunization
- B. Artificially acquired passive
- C. Artificially acquired active immunization immunization
- D. Passive immunization
Correct Answer: D
Rationale: The correct answer is D: Passive immunization. This involves administering pre-formed antibodies to provide immediate protection. In the case of a pregnant client needing temporary protection from chickenpox, passive immunization is necessary as it offers immediate immunity without stimulating the client's immune system.
- A (Naturally acquired active immunization): This involves exposure to the pathogen and the body producing its antibodies, which takes time and is not suitable for immediate protection.
- B (Artificially acquired passive immunization): This option doesn't involve providing pre-formed antibodies, which are needed for immediate protection.
- C (Artificially acquired active immunization): This method requires time for the body to develop its immunity, not providing immediate protection as needed in this scenario.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: B
Rationale: Rationale:
B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage.
A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?
- A. Serving small portions bland food
- B. Encouraging rhythmic breathing exercises
- C. Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed
- D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Correct Answer: C
Rationale: The correct answer is C because administering antiemetic medications like metoclopramide and dexamethasone helps control nausea and vomiting post-chemotherapy. Metoclopramide acts on the gut to reduce nausea, while dexamethasone decreases inflammation and suppresses the vomiting reflex. Choice A focuses on dietary interventions but does not address the physiological cause of nausea. Choice B with breathing exercises may help some clients but does not directly address the nausea and vomiting. Choice D is incorrect as withholding fluids can lead to dehydration, which is not recommended after chemotherapy.