Nokea
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.
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To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:
- A. A tracheostomy set
- B. A hypothermia blanket
- C. An intravenous set-up
- D. A syringe and edrophonium HCl(Tensilon)
Correct Answer: B
Rationale: The correct answer is B: A hypothermia blanket. This is important because hypothermia can lead to complications such as shivering, increased risk of infection, and altered drug metabolism. Checking for the hypothermia blanket ensures Mrs. Zeno's temperature is regulated, promoting safety.
A: A tracheostomy set is not directly related to Mrs. Zeno's immediate safety unless she has a tracheostomy in place.
C: An intravenous set-up is important for administering medications, fluids, or blood products, but it is not directly related to Mrs. Zeno's safety at the bedside.
D: A syringe and edrophonium HCl(Tensilon) is specific to a diagnostic test for myasthenia gravis, which may not be relevant to Mrs. Zeno's current condition or safety.
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.
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.
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. The nurse needs to revise the collaborative problem part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. A collaborative problem involves potential complications that require both nursing and medical interventions. In this case, impaired physical mobility is a nursing diagnosis that requires nursing interventions to address the patient's inability to ambulate. Choices A, B, and D are incorrect because they are all relevant components of a nursing diagnostic statement: A - Etiology identifies the cause of the nursing diagnosis, B - Nursing diagnosis states the health problem, and D - Defining characteristic provides evidence supporting the nursing diagnosis.
What is the primary purpose of the outcome identification and planning step of the nursing process?
- A. To collect and analyze data to establish a database
- B. To interpret and analyze data so as to identify health problems
- C. To write appropriate client-centered nursing diagnoses
- D. To design a plan of care for and with the client
Correct Answer: D
Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.