Nokea
A patient is admitted to the hospital with suspected pneumoniWhat is the first step the nurse should take in the nursing process?
- A. Diagnosis
- B. Assessment
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.
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What question would you initially ask a patient who has a positive tuberculin test?
- A. Have you recently been hospitalized?
- B. Are you a member of the homeless population?
- C. Have you received bacille Calmette-Guérin (BCG)?
- D. Have you been out of the country over the past 3 months?
Correct Answer: C
Rationale: The correct initial question to ask a patient with a positive tuberculin test is whether they have received bacille Calmette-Guérin (BCG) vaccine. This is because BCG vaccination can cause a false positive result on the tuberculin test due to cross-reactivity with the purified protein derivative (PPD) used in the test. Asking about recent hospitalization (A), homelessness (B), or recent travel out of the country (D) would not provide relevant information regarding the interpretation of the positive tuberculin test.
Expert nurses learn to attend to a pattern of assessment data and act without consciously labelling it. This is referred to as:
- A. intuition.
- B. the nursing process.
- C. clinical knowledge.
- D. diagnostic reasoning.
Correct Answer: A
Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.
Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?
- A. Head elevated to 45 degrees
- B. Have the patient lie flat
- C. Place the patient in the supine position
- D. Position the patient on their side
Correct Answer: C
Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.
When a nurse is performing a neurological assessment, which of the following is most important to assess first?
- A. Patient's reflexes
- B. Patient's cranial nerve function
- C. Patient's level of consciousness
- D. Patient's pupil response
Correct Answer: C
Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.
A nurse is teaching a patient with chronic kidney disease (CKD) about dietary changes. Which of the following statements by the patient indicates proper understanding?
- A. I should limit my intake of foods high in potassium and phosphorus.
- B. I should increase my fluid intake to stay hydrated.
- C. I can eat as much protein as I want to promote healing.
- D. I should drink more sodas for hydration.
Correct Answer: A
Rationale: The correct answer is A. In CKD, limiting potassium and phosphorus intake is crucial to prevent electrolyte imbalances and further kidney damage. Excessive protein intake can worsen kidney function, so the patient should not eat as much protein as they want. Increasing fluid intake is beneficial for hydration, but sodas are not recommended due to their high sugar and phosphorus content, which can be harmful for CKD patients. Therefore, option A is the best choice for proper understanding of dietary changes in CKD.