Nokea
A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
- A. Hypostatic pneumonia
- B. Renal calculi
- C. Pressure ulcers
- D. Thrombus formation
Correct Answer: B
Rationale: The correct answer is B: Renal calculi. Hypercalcemia can lead to the formation of kidney stones (renal calculi) due to increased levels of calcium in the blood being excreted by the kidneys. The nurse should monitor for signs and symptoms of renal colic, such as severe flank pain, hematuria, and urinary urgency.
Incorrect choices:
A: Hypostatic pneumonia - Hypercalcemia does not directly lead to pneumonia.
C: Pressure ulcers - Hypercalcemia does not increase the risk of pressure ulcers.
D: Thrombus formation - While hypercalcemia can predispose to blood clot formation, it is not the most closely monitored condition in this scenario.
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A home health nurse is discussing dangers of carbon monoxide poisoning with a client. What information should the nurse include?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with hemoglobin in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is correct because carbon monoxide binds with hemoglobin in the blood more easily than oxygen, leading to decreased oxygen delivery to tissues. This can result in symptoms of carbon monoxide poisoning.
A: Carbon monoxide is odorless, so this is incorrect.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body by interfering with oxygen transport, not by directly damaging the lungs.
In summary, choice D is correct because it explains the mechanism of carbon monoxide poisoning, while the other choices are incorrect as they do not directly relate to the dangers of carbon monoxide poisoning.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face
- D. neck
- E. chest
Correct Answer: C
Rationale: The correct answer is C: Client with partial & full-thickness burns to face. This client is the highest priority due to airway compromise risk from facial burns. Airway is a top priority in mass casualty events to prevent respiratory distress or failure. Crush injuries (A) may be severe but not immediately life-threatening. Laceration (B) to head can be managed with proper wound care. Clients with neck (D) or chest (E) injuries may have potential serious complications, but airway takes precedence in this scenario.
The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? Select all that apply.
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
- F. What are your medical problems that may have caused the fall?
Correct Answer: A, B, C, D
Rationale: The correct answers are A, B, C, and D. The SPLATT acronym stands for Symptoms, Previous falls, Location, Activity during the fall, Time of the fall, and Trauma sustained. Therefore, the nurse should ask where the patient fell (A), what time the fall occurred (B), what the patient was doing when they fell (C), and what types of injuries occurred after the fall (D) to gather comprehensive information about the fall event. These questions help assess the circumstances surrounding the fall, potential risk factors, and any resulting injuries. Choices E and F are incorrect as they do not directly align with the components of the SPLATT acronym and may not provide relevant information for assessing the fall event.
Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn?
- A. I don't want my spouse to see my incision
- B. Will you be able to give me pain meds after surgery?
- C. Can you tell me about how long the surgery will take?
- D. My roommate listens to everything I say
Correct Answer: C
Rationale: The correct answer is C because the client is showing readiness to learn by asking a relevant question about the surgery process. This indicates an active interest in understanding what will happen during the procedure, which is crucial for preparing mentally and emotionally. Choice A is more focused on personal discomfort, not readiness to learn. Choice B is about pain management, not understanding the surgical process. Choice D is unrelated to the situation.
Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable with the nurse.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction during procedures.
E: Engaging the child in pretend play with a toy medical kit can help familiarize the child with medical procedures in a non-threatening way.
Summary:
B: Clustering invasive procedures may not directly address the child's fear and can still be overwhelming.
C: Assigning caregivers familiar to the child may help in general care but may not directly address the fear of painful procedures.
F, G: No additional answer choices provided.