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A patient diagnosed with Heart Failure would like the nurse to explain what the diagnosis means. How will the nurse explain heart failure?
- A. The heart muscle cannot pump effectively, causing a backup of blood.
- B. Increased protein leads to reduced oncotic pressure and inability to pull the fluid into the system.
- C. The hydrostatic pressure pushing fluids out of the capillary is lower than the oncotic pressure.
- D. The decrease in venous pressure from the backup of blood increases hydrostatic pressure.
Correct Answer: A
Rationale: The correct answer is A: The heart muscle cannot pump effectively, causing a backup of blood. This is the most accurate explanation of heart failure. In heart failure, the heart is unable to pump blood efficiently, leading to a backup of blood in the circulatory system. This can result in symptoms such as shortness of breath, fatigue, and fluid retention.
Explanation for why the other choices are incorrect:
B: Increased protein leading to reduced oncotic pressure is not a direct cause of heart failure.
C: This choice describes the forces involved in fluid movement, not the primary mechanism of heart failure.
D: Heart failure causes a backup of blood, which in turn increases venous pressure, not the other way around.
In summary, choice A is correct as it directly addresses the primary issue of heart failure, while the other choices focus on different physiological processes not directly related to heart failure.
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What would be the best source of drug information for a nurse?
- A. Drug Facts and Comparisons.
- B. A nurse drug guide.
- C. A drug package insert.
- D. The Physician's Drug Reference.
Correct Answer: B
Rationale: The correct answer is B: A nurse drug guide. Nurse drug guides are specifically designed to provide concise and relevant drug information tailored for nursing practice. They include essential details such as dosages, administration routes, side effects, and nursing considerations. Drug Facts and Comparisons (A) is more comprehensive and may contain overwhelming information not directly relevant to nursing practice. Drug package inserts (C) are detailed but not user-friendly for quick reference. The Physician's Drug Reference (D) is aimed at physicians, focusing more on diagnosis and treatment rather than nursing care.
The nurse is preparing to assist with blood collection on a newly admitted patient who has been taking phenytoin for several years. The provider has ordered a complete blood count and liver function tests. Which other blood test will the nurse discuss with the provider?
- A. Coagulation studies.
- B. Serum electrolytes.
- C. Renal function tests.
- D. Blood glucose.
Correct Answer: D
Rationale: The correct answer is D: Blood glucose. Phenytoin can potentially affect blood glucose levels by causing hyperglycemia. Monitoring blood glucose levels is important to ensure the patient's safety and adjust medication dosages if needed.
Other choices are incorrect:
A: Coagulation studies are not typically affected by phenytoin therapy.
B: Serum electrolytes may need monitoring for other reasons, but not specifically related to phenytoin use.
C: Renal function tests are important for monitoring kidney function but are not directly influenced by phenytoin.
The nurse is helping develop a plan of care for a patient that has advanced Alzheimer's disease. The patient will be taking a new medication. Which is a realistic goal for this patient?
- A. Exhibit ability to provide self-care.
- B. Show improved memory for recent events.
- C. Receive appropriate assistance for care needs.
- D. Demonstrate improved cognitive function.
Correct Answer: C
Rationale: The correct answer is C: Receive appropriate assistance for care needs. For a patient with advanced Alzheimer's disease, improving memory or cognitive function is unrealistic due to the progressive nature of the disease. Providing self-care may also be beyond their ability. Setting a goal for the patient to receive appropriate assistance for care needs is realistic and important for maintaining their quality of life and safety. This goal focuses on ensuring the patient's basic needs are met and promoting their overall well-being despite their cognitive decline. It prioritizes practical support and enhances the patient's quality of life.
A nurse is caring for a six-year-old child who had surgery that morning. The child is awake and lying very still in bed. What should the nurse do?
- A. Use an “ouch†scale for pain assessment.
- B. Encourage the child to request pain medication when needed.
- C. Plan to administer pain medication if the child begins to cry.
- D. Ask the child to rate their pain on a scale of 1 to 10.
Correct Answer: A
Rationale: The correct answer is A: Use an "ouch" scale for pain assessment. This approach is appropriate for a six-year-old child as it uses a simple and understandable method to assess pain levels. The child may not verbalize pain or cry, so using a visual scale like an "ouch" scale can help the nurse accurately assess the child's pain level. Encouraging the child to request pain medication (B) assumes the child will always feel comfortable expressing their needs, which may not be the case. Planning to administer pain medication if the child cries (C) may lead to unnecessary medication administration if the child is not in pain. Asking the child to rate their pain on a scale of 1 to 10 (D) may be too complex for a young child to understand and communicate effectively.
The nurse is performing an assessment on a patient who will begin taking propranolol (Inderol) to treat hypertension. The nurse learns that the patients have a history of asthma and diabetes. The nurse will take which action.
- A. Request an order for a renal function test prior to the administration of this drug.
- B. Teach the patient about the risk of combining herbal medication with this drug.
- C. Contact the doctor to discuss another type of antihypertensive medication.
- D. Administer the medication and monitor the patient's serum glucose level.
Correct Answer: C
Rationale: Correct Answer: C - Contact the doctor to discuss another type of antihypertensive medication.
Rationale: Propranolol is a non-selective beta-blocker that can exacerbate asthma due to its potential bronchoconstrictive effects. Additionally, beta-blockers can mask signs of hypoglycemia in patients with diabetes, making it challenging to monitor blood glucose levels effectively. Therefore, it is crucial for the nurse to contact the doctor to discuss an alternative antihypertensive medication that is safe for the patient with a history of asthma and diabetes.
Summary of other choices:
A: Requesting a renal function test is not directly related to the patient's history of asthma and diabetes, which are more concerning in this case.
B: Teaching about combining herbal medication does not address the potential risks of propranolol in patients with asthma and diabetes.
D: Administering the medication without addressing the compatibility with the patient's conditions can lead to adverse effects and is not