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A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention?
- A. The patient will ambulate in the hallway twice this shift using crutches correctly.
- B. Impaired physical mobility related to inability to bear weight on right leg. Provide assistance while the patient walks in the hallway twice this shift with
- C. crutches.
- D. The patient is unable to bear weight on right lower extremity.
Correct Answer:
Rationale: Correct Answer: A: The patient will ambulate in the hallway twice this shift using crutches correctly.
Rationale:
1. This choice outlines a specific nursing intervention - ambulating with crutches.
2. It includes clear actions for the patient to ambulate and specifies using crutches correctly.
3. It addresses the patient's physical mobility needs actively.
4. It focuses on promoting independence and functional ability.
Summary of other choices:
B: This choice includes the nursing diagnosis and the plan but lacks the specificity of the correct answer.
C: This choice includes the nursing diagnosis and specifies the use of crutches but lacks the clarity of correct implementation.
D: This choice only identifies the patient's condition without providing a specific nursing intervention.
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Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to collect objective data directly from the patient, which is crucial in establishing a comprehensive patient database. By assessing the patient's physical condition, the nurse can gather vital information such as vital signs, overall health status, and potential areas of concern. Reviewing literature (A) and checking orders for tests (B) may provide additional insights but are not direct data collection methods. Ordering medications (D) is a treatment intervention, not a data collection method.
A diabetic client develops sinusitis and otitis media accompanied by a fever of 100.8○0 F (38.2○0 C). What effect may this have on his need for insulin?
- A. It will have no effect.
- B. it will cause wide fluctuations in the
- C. it will decrease the need insulin. need for insulin
- D. It will increase the need for insulin.
Correct Answer: D
Rationale: The correct answer is D: It will increase the need for insulin. Infections like sinusitis and otitis media can lead to increased stress on the body, causing insulin resistance and higher blood sugar levels. This leads to an increased demand for insulin to regulate blood sugar levels effectively. Therefore, the diabetic client's need for insulin will likely increase in this scenario.
Incorrect choices:
A: It will have no effect - Incorrect because infections and fever can impact insulin requirements.
B: It will cause wide fluctuations in the need for insulin - Incorrect as infections generally lead to increased insulin needs, not fluctuations.
C: It will decrease the need for insulin - Incorrect as infections and fever typically increase insulin requirements due to increased stress on the body.
Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:
- A. cover wound with moist sterile dressing
- B. find out how this happened
- C. place sterile dry gauze on the wound
- D. pour sterile water into the wound
Correct Answer: A
Rationale: Correct Answer: A: Cover wound with moist sterile dressing
Rationale:
1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing.
2. Moist dressing prevents the wound from drying out and minimizes the risk of infection.
3. The moist environment supports healing by promoting cell growth and preventing tissue damage.
4. It protects the exposed bowel from further injury and contamination.
Summary:
B: Finding out how this happened is important but not an immediate priority for patient care.
C: Placing sterile dry gauze can lead to the wound drying out and hinder healing.
D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.
Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather patient data through observation, palpation, percussion, and auscultation. It helps in assessing the patient's overall health status, identifying any abnormalities, and establishing a baseline for further care. Reviewing literature (A) helps in evidence-based practice but does not directly collect patient data. Checking orders for tests (B) and ordering medications (D) involve actions based on data collected rather than collecting the data itself.
The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client’s health status. Which of the following would the nurse identify as a subjective cue?
- A. Sharp pain in the knee
- B. Small bloody drainage on dressing
- C. Temperature of 102 degrees F
- D. Pulse rate of 90 beats per minute
Correct Answer: A
Rationale: The correct answer is A because sharp pain is a subjective cue as it is based on the client's personal experience and perception. The client is the only one who can report the presence and intensity of pain.
B: Small bloody drainage is an objective cue that can be observed and measured by the nurse.
C: Temperature of 102 degrees F is an objective cue that can be measured using a thermometer.
D: Pulse rate of 90 beats per minute is an objective cue that can be measured using a pulse oximeter.
In summary, subjective cues are based on the client's feelings and perceptions, while objective cues are observable and measurable by the healthcare provider.