Nokea
A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)
- A. Includes seven domains for level 1
- B. Uses an easy 3-point Likert scale
- C. Adds objectivity to judging a patient’s progress
- D. Allows choice in which interventions to choose
Correct Answer: C
Rationale: The correct answer is C because Nursing Outcomes Classification adds objectivity to judging a patient's progress by providing standardized criteria for assessing outcomes. This helps in evaluating the effectiveness of interventions and tracking improvements accurately. Other choices are incorrect: A is wrong because Nursing Outcomes Classification includes 7 domains but not necessarily for level 1; B is incorrect as it uses a 5-point Likert scale, not a 3-point scale; and D is inaccurate because Nursing Outcomes Classification guides the selection of interventions based on the identified outcomes, not allowing complete freedom in choosing interventions.
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A client has cancer that has me tastasized to her bones. She is complaining of increased thirst, polyuria and decreased muscle tone. Her lab values are: Na 139mEq/L, k 4 mEq/L, Cl 103 mEq/L, and Ca 8 mg/dl. What electrolyte imbalance is present?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hypercalcemia
- D. Hypochloremia
Correct Answer: C
Rationale: The correct answer is C: Hypercalcemia. Increased thirst and polyuria are symptoms of hypercalcemia, as excess calcium can lead to dehydration and increased urine output. Decreased muscle tone is also a common symptom of hypercalcemia. The lab value of Ca 8 mg/dl confirms high levels of calcium in the blood.
Incorrect choices:
A: Hypocalcemia - This is incorrect as the lab value of Ca 8 mg/dl indicates normal to high levels of calcium, ruling out hypocalcemia.
B: Hyperkalemia - This is incorrect as the lab value of K 4 mEq/L is within normal range, ruling out hyperkalemia.
D: Hypochloremia - This is incorrect as the lab value of Cl 103 mEq/L is within normal range, ruling out hypochloremia.
Which of the following terms indicates that the patient has a hearing loss caused by aging?
- A. Otoplasty
- B. Presbycusis
- C. Otalgia
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
- A. Stand as far away from the implant as possible and call for help.
- B. Pick up the implant with long-handled forceps and place it in a lead-lined container.
- C. Leave the room and notify the radiation therapy department immediately.
- D. Put the implant back in place, using forceps and a shield for self-protection, and call for help.
Correct Answer: D
Rationale: The correct answer is D. First, the nurse should put the implant back in place using forceps and a shield for self-protection. This is important to limit the exposure to radiation for both the client and the nurse. Second, the nurse should call for help to ensure proper handling and further assistance. Standing away from the implant (choice A) does not address the immediate need to secure the implant. Picking up the implant with long-handled forceps and placing it in a lead-lined container (choice B) should only be done by trained personnel to prevent further exposure. Leaving the room and notifying the radiation therapy department immediately (choice C) delays the immediate action needed to prevent unnecessary radiation exposure.
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
- A. No sputum or cough present in 4 days
- B. Congestion throughout all lung fields in 2 days
- C. Shallow, fast respirations 30 breaths per minute in 1 day
- D. Lungs clear to auscultation following use of inhaler
Correct Answer: D
Rationale: The correct evaluative measure is D: Lungs clear to auscultation following use of inhaler. This choice aligns with the expected outcome of having no secretions present in the lungs in 48 hours. By using an inhaler to clear the lungs, the nurse can assess if the expected outcome is being met. This measure directly evaluates the presence of secretions in the lungs, in line with the established goal.
Incorrect Choices:
A: No sputum or cough present in 4 days - This measure does not align with the expected outcome of having no secretions present in the lungs in 48 hours.
B: Congestion throughout all lung fields in 2 days - This indicates a worsening condition and does not demonstrate progress towards the goal.
C: Shallow, fast respirations 30 breaths per minute in 1 day - This measure is unrelated to the presence of secretions in the lungs and the goal of avoiding shortness of breath with activity.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. In the first phase of the nursing process (assessment), the nurse collects data to form a comprehensive database about the patient's health status. This step is crucial as it provides the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining whether outcomes have been achieved (D) is in the fourth phase (evaluation). Completing a comprehensive database in the first phase ensures a thorough understanding of the patient's needs before proceeding to the next steps in the nursing process.