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A nurse is discharging a client from the hospital. When should discharge planning be initiated?
- A. At the time of discharge from an acute health care setting
- B. At the time of admission to an acute health care setting
- C. Before admission to an acute health care setting
- D. When the client is at home after acute care
Correct Answer: B
Rationale: Rationale:
1. Discharge planning should start at admission to ensure comprehensive preparation.
2. Early planning allows for assessment of needs and coordination of resources.
3. It promotes continuity of care and reduces risks of readmission.
4. Options A, C, and D are incorrect as they miss the opportunity for proactive planning.
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Mr. Ramos consulted at the health center for follow up after one month of Isoniazid and Rifampicin. Which diagnostic test will have an abnormal result if the client is taking these medications?
- A. gallbladder studies
- B. thyroid function tests
- C. liver function tests
- D. blood sugar levels
Correct Answer: C
Rationale: The correct answer is C: liver function tests. Isoniazid and Rifampicin are known to potentially cause hepatotoxicity, leading to abnormal liver function test results. Liver function tests measure enzymes and proteins that indicate liver health. Gallbladder studies (A), thyroid function tests (B), and blood sugar levels (D) are not directly affected by these medications and would not show abnormal results due to their use.
Which is the most reliable method for monitoring fluid balance?
- A. Daily intake and output
- B. Vital signs
- C. Daily weight
- D. Skin turgor
Correct Answer: A
Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.
The following would be a symptom the nurse would expect to find during assessment of a patient with macular degeneration, EXCEPT:
- A. Decreased ability to distinguish colors
- B. Loss of central vision
- C. Loss of near vision
- D. Loss of peripheral vision
Correct Answer: D
Rationale: The correct answer is D: Loss of peripheral vision. Macular degeneration affects the central vision, specifically the macula, which is responsible for central vision and sharp detail. Loss of peripheral vision is not a typical symptom of macular degeneration. The macula is located in the center of the retina, so symptoms would relate to central vision impairments such as decreased ability to distinguish colors, loss of central vision, and loss of near vision. Peripheral vision is not primarily affected by macular degeneration, hence it is not an expected symptom.
The nurse is teaching a client with type 1 diabetes mellitus how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn’t always a possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
- A. Epinephrine
- B. 50% dextrose
- C. Glucagon
- D. Hydrocortisone
Correct Answer: C
Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.
A nurse teaches a client newly diagnosed with diabetes how to administer insulin. What type of nursing intervention is this?
- A. Independent intervention
- B. Dependent intervention
- C. Interdependent intervention
- D. Collaborative intervention
Correct Answer: A
Rationale: Correct Answer: A (Independent intervention)
Rationale:
1. Independent interventions are actions that nurses can initiate without a doctor's order.
2. Teaching a client how to administer insulin falls under the scope of nursing practice.
3. Nurses have the knowledge and authority to educate clients on self-care management.
4. This intervention does not require collaboration with other healthcare providers.
Summary:
B: Dependent interventions require a doctor's order.
C: Interdependent interventions involve collaboration with other healthcare providers.
D: Collaborative interventions involve working with other healthcare professionals.