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A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B because the problem-oriented approach involves focusing on the patient's presenting situation to identify the main issues and prioritize data collection. This step helps the nurse understand the immediate concerns and sets the direction for further assessment and interventions.
Choice A is incorrect because completing questions in chronological order may not address the most urgent issues. Choice C is incorrect as accurate interpretations come after collecting relevant data. Choice D is incorrect as conducting an observational overview is part of the assessment process but not the first step in the problem-oriented approach.
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The normal life expectancy for 50% of patients ith amyotropic lateral sclerosis (ALS) is:
- A. 3 years
- B. 10 years
- C. 5 years
- D. 20 years
Correct Answer: C
Rationale: The correct answer is C: 5 years. In ALS, 50% of patients have a life expectancy of around 3-5 years from the time of diagnosis. This is due to the progressive nature of the disease, leading to rapid deterioration of motor neurons and muscle function. Choice A (3 years) is too specific and may not apply to exactly 50% of patients. Choice B (10 years) and D (20 years) are too optimistic and do not align with the typical prognosis of ALS, where the majority of patients have a shorter life expectancy. Therefore, based on the average survival rates and disease progression, choice C is the most accurate representation of the normal life expectancy for 50% of ALS patients.
Which of the ff interventions is implemented for a client with empyema?
- A. Teach the client breathing exercises
- B. Offer assurance that empyema takes less time to resolve
- C. Recommend that the client eat a balanced but light diet
- D. Emphasize the completion of the entire course of drug therapy
Correct Answer: D
Rationale: The correct answer is D: Emphasize the completion of the entire course of drug therapy. Empyema is a serious condition that requires antibiotic treatment. Emphasizing the completion of the entire course of drug therapy is crucial to ensure that the infection is completely eradicated and to prevent the development of drug-resistant strains. Teaching breathing exercises (choice A) may help improve lung function but is not the primary intervention for empyema. Offering assurance that empyema takes less time to resolve (choice B) is incorrect as it can mislead the client about the seriousness of the condition. Recommending a balanced but light diet (choice C) may be beneficial for overall health but is not directly related to treating empyema.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.
Which of the following reflects the importance of client-centered care during the evaluation phase?
- A. Evaluating based solely on physician recommendations.
- B. Assessing whether the care plan aligns with the client’s preferences and goals.
- C. Prioritizing institutional policies over client feedback.
- D. Focusing evaluation on measurable clinical outcomes only.
Correct Answer: B
Rationale: The correct answer is B because client-centered care emphasizes involving clients in decision-making. During evaluation, assessing if the care plan aligns with the client's preferences and goals ensures personalized and effective care. This approach enhances client satisfaction, engagement, and outcomes.
Incorrect choices:
A: Not considering the client's input goes against client-centered care principles.
C: Prioritizing institutional policies over client feedback neglects the client's individual needs.
D: Focusing solely on measurable clinical outcomes may not capture the holistic view of the client's well-being.
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.