Nokea
A nurse is explaining to the nursing students working on the antepartum unit how to assess for edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? N R I G B.C M U S N T O
- A. +1
- B. +2
- C. +3
- D. 4
Correct Answer: C
Rationale: Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as
+1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities
is +2 edema. Generalized massive edema (+4) includes the accumulation of fluid in the
peritoneal cavity.
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The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work? What would be the nurses best response?
- A. Yes, its known to have a slight protective effect.
- B. Yes, but studies also show an increased risk of osteoporosis.
- C. You wont need to worry about getting cancer as long as you take Tamoxifen.
- D. Tamoxifen is known to be a highly effective protective measure.
Correct Answer: A
Rationale: The nurse's best response should be to provide accurate information and manage the patient's expectations realistically. Tamoxifen is known to have a slight protective effect in reducing the risk of developing breast cancer in high-risk individuals like the patient in the scenario. However, it is not a guarantee against developing breast cancer. It is essential for the nurse to convey this information to the patient to ensure that she understands the benefits and limitations of Tamoxifen therapy. Additionally, discussing potential side effects and risks associated with Tamoxifen, such as an increased risk of osteoporosis, is important for the patient to make an informed decision about her health care.
A preceptor is working with a new nurse on documentation.Which situation will cause the preceptor to follow up?
- A. The new nurse documents only for self.
- B. The new nurse charts consecutively on every other line.
- C. The new nurse ends each entry with signature and title.
- D. The new nurse keeps the password secure.
Correct Answer: B
Rationale: The preceptor would need to follow up with the new nurse for charting consecutively on every other line. This behavior is incorrect as it can lead to confusion and potential errors in documentation. Correct charting practice involves documenting consecutively, line by line without skipping lines in between. The preceptor should provide guidance and correction to ensure accurate and organized documentation for patient care.
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
- A. Page the physician and report this sign of infection.
- B. Reinforce the dressing and reassess in 1 to 2 hours.
- C. Reposition the patient to prevent further hemorrhage.
- D. Inform the surgeon of the possibility of a dural leak.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when observing the surgical dressing saturated with serosanguineous drainage is to reinforce the dressing and reassess in 1 to 2 hours. Serosanguineous discharge is a common type of drainage following surgery, as it is a mixture of blood and serum. It is expected in the early stages of wound healing and does not necessarily indicate infection. By reinforcing the dressing and closely monitoring the drainage over the next couple of hours, the nurse can assess if the amount of drainage is decreasing or escalating. If there are any signs of infection, such as increasing redness, warmth, swelling, or excessive purulent discharge, then the nurse should notify the physician promptly. Until then, it is appropriate to continue observing and managing the drainage within the expected range.
When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan?
- A. Increasing carbohydrates to 55% to 60% of total intake
- B. Providing vitamin and mineral supplements
- C. Decreasing protein intake to 0.75 g/kg/day
- D. Limiting water before and after exercise
Correct Answer: A
Rationale: When planning care for an adolescent who plays sports, it is important to provide adequate nutrition to meet their increased energy needs. Carbohydrates are the main source of energy, providing fuel for physical activity. Adolescents engaged in sports require a higher carbohydrate intake and should aim for 55% to 60% of their total daily kilocalories to support their activity levels. Carbohydrates are essential for providing energy during exercise, building and repairing muscles, and promoting overall performance. Increasing carbohydrate intake in the diet is a key modification to support the energy demands of an active adolescent involved in sports.
Which disease process improves during pregnancy?
- A. Epilepsy
- B. Bell’s palsy
- C. Rheumatoid arthritis
- D. Systemic lupus erythematosus (SLE)
Correct Answer: C
Rationale: Rheumatoid arthritis shows marked improvement during pregnancy, although the reason for this is not entirely clear. The improvement is often significant, leading to relief from symptoms for many pregnant individuals with this condition. However, it's important to note that this improvement is temporary, as relapse typically occurs within 36 months postpartum. The exact mechanisms behind this temporary improvement are not fully understood, but hormones and changes in the immune system during pregnancy are believed to play a role in modifying the disease process.