Nokea
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
- A. Anxiety related to barium enema
- B. Impaired gas exchange related to asthma
- C. Impaired physical mobility related to incisional pain
- D. Nausea related to adverse effect of cancer medication
Correct Answer: A
Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs.
Summary:
B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition.
C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself.
D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.
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A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
- A. Indwelling urinary catheter kit
- B. Cardiac monitor
- C. Tracheostomy set
- D. Humidifier
Correct Answer: C
Rationale: Correct Answer: C - Tracheostomy set
Rationale:
1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway.
2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention.
3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment.
Summary of other choices:
A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care.
B: Cardiac monitor - Important but secondary to airway management in this situation.
D: Humidifier - Not essential for immediate post-thyroidectomy care.
A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
- A. 13 gtt/min
- B. 29 gtt/min
- C. 16 gtt/min
- D. 32 gtt/min Situation 5: Protection of self and patient can be done by supporting the body's immunity.
Correct Answer: B
Rationale: To calculate the drip rate, we first need to find the total volume of IV fluid to be administered, which is 1500 ml + 1250 ml = 2750 ml. Then, we multiply the total volume by the drop factor (2750 ml * 15 gtt/ml = 41250 gtt). Finally, we divide the total number of drops by the time in minutes (24 hours * 60 min = 1440 min) to get the drip rate: 41250 gtt / 1440 min = 28.47 gtt/min, which rounds up to 29 gtt/min. Therefore, choice B is correct. Choices A, C, and D are incorrect because they do not reflect the accurate calculation based on the given parameters.
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
- A. Above-normal urine and serum osmolality levels
- B. Below-normal urine and serum osmolality levels
- C. Above-normal urine osmolality level, below-normal serum osmolality level
- D. Below- normal urine osmolality level, above-normal serum osmolality level
Correct Answer: D
Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus.
Explanation for other choices:
A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus.
B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus.
C: Above-normal urine osmolality level, below-normal
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
- A. breath sounds
- B. blood pressure
- C. capillary refill
- D. butterfly rash
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct:
1. Blood pressure is vital in this scenario due to prednisone discontinuation.
2. Abruptly stopping prednisone can lead to adrenal insufficiency.
3. Adrenal insufficiency can cause hypotension, a life-threatening condition.
4. Monitoring blood pressure can help detect and manage potential complications.
Summary of other choices:
A: Breath sounds – Important but not the priority in this specific situation.
C: Capillary refill – Useful for assessing circulation but not urgent in this context.
D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?
- A. Night sweats, weight loss, and diarrhea
- B. Nausea, vomiting, and anorexia
- C. Dyspnea, tachycardia, and pallor
- D. Itching, rash, and jaundice A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET H
Correct Answer: C
Rationale: Rationale:
1. Anemia results in decreased oxygen-carrying capacity, leading to tissue hypoxia.
2. Dyspnea (shortness of breath) occurs due to the body's attempt to increase oxygen intake.
3. Tachycardia (rapid heart rate) compensates for decreased oxygen delivery.
4. Pallor (pale skin) is a classic sign of decreased red blood cells in iron-deficiency anemia.
Summary:
A: Night sweats, weight loss, and diarrhea are not typical manifestations of iron-deficiency anemia.
B: Nausea, vomiting, and anorexia are non-specific symptoms and not specific to iron-deficiency anemia.
D: Itching, rash, and jaundice are not commonly associated with iron-deficiency anemia.