Nokea
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
- A. The written outcomes are designed to meet nursing goals
- B. To encourage the client and family to be involved
- C. To discourage additions by other healthcare providers
- D. Why the nurse believes the outcome is important
Correct Answer: B
Rationale: The correct answer is B because involving the client and family in developing outcomes promotes patient-centered care and increases the likelihood of achieving successful outcomes. This approach fosters collaboration, shared decision-making, and empowers the client and family in their own care. It also helps to ensure that the outcomes align with the client's values, preferences, and goals. Choices A, C, and D are incorrect because focusing solely on nursing goals without considering the client's perspective may lead to a lack of engagement and poor outcomes. Discouraging input from other healthcare providers limits the interdisciplinary approach to care, and focusing on why the nurse believes the outcome is important neglects the client's role in the decision-making process.
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Which laboratory study is monitored for the patient receiving heparin therapy?
- A. INR
- B. PTT
- C. PT
- D. Bleeding time
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect.
A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin.
C: PT (Prothrombin Time) is also used to monitor warfarin therapy.
D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
- A. Hand bell and extra bed linen
- B. Footboard and splint
- C. Sandbag and trochanter rolls
- D. Suction machine and gloves
Correct Answer: C
Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning.
Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation.
Step 3: These help prevent pressure ulcers and maintain proper body alignment.
Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care.
Step 5: Footboard and splint may not be relevant to his specific condition.
Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco.
Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.
Which of the ff would help a client with an allergic skin reaction to reduce itching and maintain skin intact? Choose all that apply
- A. Humidifying the environment
- B. Avoiding a skin lubricant
- C. Bathing with a bar soap that contains lye
- D. Wearing cotton gloves, esp during sleep
Correct Answer: D
Rationale: The correct answer is D. Wearing cotton gloves, especially during sleep, helps reduce itching by preventing scratching, which can further irritate the skin. Cotton is a breathable fabric that reduces friction and irritation.
A: Humidifying the environment may help in some cases, but it doesn't directly address the itching or maintaining skin integrity.
B: Avoiding a skin lubricant is not recommended as it can help moisturize the skin and reduce itching.
C: Bathing with a bar soap that contains lye can be harsh and drying, exacerbating the skin reaction.
Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:
- A. respiratory compromise related to inhalation of smoke
- B. pneumonia related to prolonged bedrest
- C. fat embolism syndrome related to femur fracture
- D. hypovolemic shock related to multiple trauma
Correct Answer: C
Rationale: The correct answer is C: fat embolism syndrome related to femur fracture. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress. In this case, the patient's femur fracture likely led to fat embolism, explaining her dyspnea, tachypnea, crackles, and thick sputum. Choices A, B, and D do not align with the patient's presentation and history, making them incorrect. Choice A suggests smoke inhalation, which is not supported by the scenario. Choice B mentions pneumonia from bedrest, which is not a common complication of immobility. Choice D proposes hypovolemic shock from multiple trauma, which does not explain the respiratory symptoms and sputum production observed in the patient.
When testing visual fields, the nurse is assessing which of the following parts of vision?
- A. Peripheral vision
- B. Distance vision
- C. Near vision
- D. Central vision
Correct Answer: A
Rationale: The correct answer is A: Peripheral vision. When testing visual fields, the nurse evaluates the ability to see objects outside the direct line of sight, which is indicative of peripheral vision. Peripheral vision helps detect objects and movement in the side vision. Distance vision (B) refers to the ability to see clearly at a distance, while near vision (C) pertains to close-up vision. Central vision (D) is essential for focusing on details and seeing straight ahead. Therefore, A is the correct choice as it specifically pertains to the assessment of visual fields.