Nokea
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: B
Rationale: Rationale:
B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage.
A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.
You may also like to solve these questions
Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
- A. 2-5 mmHg
- B. 10-15 mmHg
- C. 5-10 mmHg
- D. 20-25 mmHg
Correct Answer: B
Rationale: The correct answer is B (10-15 mmHg) because this range is considered safe and effective for suctioning in most cases. Lower suction pressures (such as 2-5 mmHg) may not effectively clear secretions, while higher pressures (20-25 mmHg) can cause tissue damage. Choice C (5-10 mmHg) falls within the safe range but may not provide enough suction for effective clearance. Therefore, the optimal suction pressure for James using the portable suction unit at home is 10-15 mmHg.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C. The nurse can infer that the patient is apprehensive about discharge based on the subjective data of the patient expressing fear of going home and being alone. This indicates the patient may not feel ready to leave the hospital setting. Choice A is incorrect because the patient's fear of going home suggests they may not be comfortable performing dressing changes alone. Choice B is incorrect because there is no information provided to support that the patient can begin retaking all previous medications. Choice D is incorrect as there is no indication that the fear of going home is related to the success of the surgery.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect as it assumes the patient's fear is related to dressing changes, not discharge. Choice B is incorrect as resuming medications is not linked to the patient's fear of being alone. Choice D is incorrect as there is no indication in the scenario that the surgery was unsuccessful.
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
- A. Determines whether an intervention is correct and appropriate for the given situation
- B. Reads over the steps and performs a procedure despite lack of clinical competency
- C. Establishes goals for a particular patient without assessment
- D. Evaluates the effectiveness of interventions
Correct Answer: A
Rationale: The correct answer is A because determining whether an intervention is correct and appropriate for the given situation indicates critical thinking in nursing care implementation. This involves assessing the patient's needs, analyzing the situation, and using evidence-based practice to make informed decisions. This process ensures that interventions are tailored to individual patient needs and promotes safe and effective care delivery.
Option B is incorrect because performing a procedure without clinical competency can jeopardize patient safety and is not an example of critical thinking. Option C is incorrect as establishing goals without assessment lacks a foundation in data and may lead to inappropriate care planning. Option D is incorrect as evaluating the effectiveness of interventions is a part of the nursing process but does not specifically demonstrate critical thinking in implementation.
Why is heart biopsy performed throughout a clients lifetime after heart transplantation?
- A. To detect rejection
- B. To check the heart functionality
- C. To check rate of the heartbeat
- D. To check for heart tumor CARING FOR CLIENTS WITH HYPERTENSION
Correct Answer: A
Rationale: The correct answer is A: To detect rejection. After heart transplantation, heart biopsy is performed to monitor for rejection, a common complication. Tissue samples are examined for signs of rejection, such as inflammation. This is crucial for timely intervention to prevent rejection-related complications.
Other choices are incorrect:
B: Heart functionality is typically assessed through imaging tests like echocardiograms, not biopsy.
C: Heart rate monitoring can be done through non-invasive methods like electrocardiograms, not biopsy.
D: Checking for heart tumors is not a primary purpose of heart biopsy post-transplantation.