Nokea
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 because fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming all previous medications is not related to the patient's fear of going home. Choice D is incorrect as the subjective data does not provide any information about the success of the surgery.
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A 34 year old client is diagnosed with AIDS. His pharmacologic management includes zidovudine (AZT). During a home visit, the client states, “I don’t understand how this medication works. Will it stop the infection?” What is the nurse’s best response?
- A. The medication helps to slow the disease process, but it won’t cure or stop it totally
- B. The medication blocks reverse transcriptase, the enzyme required fro HIV replication
- C. Don’t you know? There aren’t medication to stop or cure HIV
- D. No. it won’t stop the infection. In fact, sometimes the HIV can become immune to the drug itself
Correct Answer: B
Rationale: The correct answer is B. The nurse should explain that zidovudine (AZT) works by blocking reverse transcriptase, the enzyme necessary for HIV replication. This is the key mechanism of action for AZT in managing HIV.
Choice A is incorrect because it provides a partial truth - it does slow the disease process but does not provide the mechanism of action. Choice C is incorrect as it provides incorrect information that there are no medications to stop or cure HIV, which is not true. Choice D is incorrect as it provides misleading information about the drug becoming immune to HIV, which is not the primary concern in this context.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise this part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. Collaborative problems are issues that require both medical and nursing interventions, whereas nursing diagnoses are within the scope of nursing practice. The etiology identifies the cause of the problem (tibial fracture), the nursing diagnosis states the problem (impaired physical mobility), and the defining characteristic is the evidence that supports the diagnosis (inability to ambulate). Therefore, the nurse should revise the part stating collaborative problem as it does not align with the nature of the issue presented in the scenario.
A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.
- A. “Do you smoke cigarettes, cigars or pipe?”
- B. “Do you eat a lot of red meat?”
- C. “Have you strained your voice recently?”
- D. “Do you eat spicy foods?”
Correct Answer: C
Rationale: The correct answer is C because asking if the client has strained their voice recently is the most relevant question to assess the issue of hopelessness. Voice strain can be a symptom of underlying emotional distress or mental health concerns, which could be contributing to the client's feelings of hopelessness. Choices A, B, and D are unrelated to the client's presenting issue and would not provide valuable information in addressing the problem at hand.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise the collaborative problem part of the diagnostic statement because "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate" is a nursing diagnosis, not a collaborative problem. Collaborative problems involve issues that require both nursing and medical interventions, whereas nursing diagnoses focus on the nurse's role in addressing the patient's health issues. Therefore, the nurse should revise the collaborative problem part to accurately reflect the collaborative aspect of the patient's care. Etiology (A), nursing diagnosis (B), and defining characteristic (D) are not the parts of the diagnostic statement that need revision in this scenario.
The staff nurse in a regional hospital is aware that a dose of parenteral ampicillin must be administered within how many hours after it has been mixed?
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 8 hours
Correct Answer: B
Rationale: The correct answer is B (4 hours) because parenteral ampicillin should be administered within 1 hour of mixing. This is crucial to ensure efficacy and prevent bacterial growth in the solution. Choice A (1 hour) is incorrect because it does not allow enough time for administration after mixing. Choice C (2 hours) is also incorrect as it exceeds the recommended time limit. Choice D (8 hours) is incorrect as it exceeds the safe window for administration post-mixing, increasing the risk of bacterial contamination and reduced effectiveness. Thus, the optimal timeframe for administering parenteral ampicillin after mixing is within 4 hours to maintain its therapeutic benefits.