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A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
- A. Assigning clinical cues
- B. Defining characteristics
- C. Diagnostic reasoning NursingStoreRN
- D. Diagnostic labeling
Correct Answer: C
Rationale: The correct answer is C: Diagnostic reasoning. Diagnostic reasoning involves using assessment data and critical thinking skills to develop a nursing diagnosis. This process includes analyzing and interpreting data to make clinical judgments about the patient's health status.
A: Assigning clinical cues is incorrect because this refers to identifying and documenting specific observations or findings during the assessment process, not the process of developing a nursing diagnosis.
B: Defining characteristics is incorrect because this refers to the specific symptoms or manifestations used to support a nursing diagnosis, not the overall process of diagnostic reasoning.
D: Diagnostic labeling is incorrect because this refers to assigning a formal name to the nursing diagnosis, not the process of critically analyzing assessment data to develop it.
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The nurse is caring for a client with type I diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
- A. I.M. or subcutaneous glucagon.
- B. I.V. bolus of dextrose 50%.
- C. 15 to 20 g of a fast-acting carbohydrate such as orange juice.
- D. 10 U of fast-acting insulin.
Correct Answer: C
Rationale: The correct answer is C: 15 to 20 g of a fast-acting carbohydrate such as orange juice. In this scenario, the client is experiencing hypoglycemia, which can lead to confusion and abnormal behavior. Administering fast-acting carbohydrates like orange juice will help quickly raise the blood sugar levels. This is the first-line treatment for conscious patients with hypoglycemia.
Choice A (I.M. or subcutaneous glucagon) is used for unconscious patients or when oral intake is not possible. Choice B (I.V. bolus of dextrose 50%) is too aggressive for a conscious patient and may lead to complications. Choice D (10 U of fast-acting insulin) would further lower the blood sugar levels and worsen the situation.
Administering fast-acting carbohydrates is the safest and most effective approach for conscious patients with hypoglycemia to quickly raise their blood sugar levels and resolve their symptoms.
A client with advanced liver cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to prescribe:
- A. Fluoxymesterone (Halotestin)
- B. Fluorouracil (5-fluorouracil, 5 FU [Fluoroplex])
- C. Tamoxifen (Nolvadex)
- D. Megestrol (Megace)
Correct Answer: B
Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5 FU [Fluoroplex]). Fluorouracil is commonly used in chemotherapy for liver cancer to inhibit cancer cell growth. It is a pyrimidine analog that interferes with DNA synthesis. Fluoxymesterone (A) is an androgen used in hormone replacement therapy, not in liver cancer treatment. Tamoxifen (C) is an antiestrogen used in breast cancer treatment, not liver cancer. Megestrol (D) is a progestin used in hormone therapy for breast cancer and endometrial cancer, not liver cancer. Therefore, the correct choice is B as it directly targets cancer cell growth in liver cancer treatment.
Which statement, from a participant attending the class on AIDS prevention, indicates an understanding on how to reduce transmission of HIV?
- A. Mother’s who are HIV positive should still be encouraged to breastfeed their babies because beast milk is superior to cow’s milk
- B. I think a needle exchange program, where clean needles are exchanged for dirty needles, should be offered in every city
- C. Females taking birth control pills are protected from getting HIV
- D. It’s okay to use natural skin condoms since they offer the same protection as the latex condoms
Correct Answer: B
Rationale: The correct answer is B. This statement shows an understanding of reducing HIV transmission by promoting harm reduction strategies like needle exchange programs, which help prevent sharing of contaminated needles. This approach is evidence-based and effective in reducing the spread of HIV among injection drug users.
Choice A is incorrect because breastfeeding by HIV-positive mothers can transmit the virus to infants. Choice C is incorrect as birth control pills do not protect against HIV, only against pregnancy. Choice D is incorrect as natural skin condoms do not provide the same level of protection against HIV as latex condoms do.
A nurse is preparing an IM injection of prednisolone acetate, 30 mg. It is supplied as 50 mg/mL. How many mL should the nurse prepare?
- A. 0.5 mL
- B. 0.7 mL
- C. 0.6 mL
- D. 0.8 mL
Correct Answer: B
Rationale: To calculate the mL needed for the injection, divide the prescribed dose by the concentration of the medication. In this case, 30 mg ÷ 50 mg/mL = 0.6 mL. However, since the nurse should round up to ensure the full dose is administered, the correct answer is 0.7 mL. Choice A is incorrect as it is rounded down. Choice C is incorrect as it is the exact division without rounding up. Choice D is incorrect as it is rounded up too much.
Why must a nurse measure the intake and output and recommend a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis?
- A. To determine the clients response to the therapy
- B. To flush out the infectious microorganisms from the urinary tract
- C. To determine the location of discomfort
- D. To detect any evidence of changes
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Measuring intake and output and recommending increased fluid intake for a client with pyelonephritis is crucial to help flush out infectious microorganisms from the urinary tract. By increasing fluid intake, the client will urinate more frequently, aiding in the removal of bacteria causing the infection. This helps in reducing the bacterial load in the urinary tract and promoting faster recovery. Monitoring intake and output also helps ensure the client is adequately hydrated.
Summary of Other Choices:
A: Monitoring intake and output is more about assessing hydration status and kidney function rather than the response to therapy.
C: Intake and output measurement does not directly determine the location of discomfort in pyelonephritis.
D: Monitoring intake and output is not primarily for detecting changes but for ensuring proper fluid balance and aiding in infection clearance.