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A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
- A. 4.0mEq/L
- B. 2.0mEq/L
- C. 8.0mE⁺q/L
- D. 2.6mEq/L
Correct Answer: B
Rationale: The correct answer is B: 2.0mEq/L. Severe vomiting can lead to hypokalemia, characterized by flat T waves and ST segment depression on ECG. This is due to decreased potassium levels affecting cardiac repolarization. A potassium level of 2.0mEq/L is dangerously low and consistent with the ECG findings in this scenario. Choices A, C, and D have potassium levels that are not reflective of severe hypokalemia, therefore they are incorrect. Option A (4.0mEq/L) is within the normal range, option C (8.0mEq/L) is elevated, and option D (2.6mEq/L) is higher than the correct value of 2.0mEq/L.
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Which of the following nursing activities is an example of evaluation?
- A. Checking a client’s blood pressure 30 minutes after administering an antihypertensive medication
- B. Administering prescribed oxygen therapy to a client
- C. Developing a plan of care for a new client
- D. Teaching a client about low-sodium dietary options
Correct Answer: A
Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D because asking the patient about their usual sleep patterns and onset of difficulty resting is crucial to understand the situation fully. This helps to identify any potential underlying issues contributing to the sleep disturbance. Choice A is incorrect as it dismisses the patient's concerns. Choice B is not as effective as directly addressing the patient's sleep issues. Choice C delays the assessment, potentially missing important information. By choosing answer D, the nurse can gather valuable information to address the patient's sleep problem effectively.
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
- A. To identify a life-threatening problem
- B. To establish a database for medical care
- C. To practice respiratory assessment skills
- D. To facilitate the resident’s ability to breathe
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe.
2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention.
3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue.
4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking.
Summary:
- Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking.
- Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database.
- Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation.
- Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.
Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Positive reinforcement helps enhance communication skills in individuals with expressive aphasia.
2. Providing positive feedback when Mr. Reyea uses words correctly encourages him to continue trying to communicate.
3. It boosts his confidence and motivation, leading to improved verbal communication over time.
Summary of why other choices are incorrect:
B. Waiting indefinitely for Mr. Reyea to verbally state his needs may lead to frustration and hinder effective communication.
C. Suggesting permanent help at home assumes Mr. Reyea's condition cannot improve, which is not necessarily true for expressive aphasia.
D. Helping the family accept Mr. Reyea's communication challenges does not actively support his communication improvement and may limit his progress.
The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
- A. Dependent NursingStoreRN
- B. Independent
- C. Interdependent
- D. Physician-initiated
Correct Answer: C
Rationale: The correct answer is C: Interdependent. In this scenario, the nurse performed an intervention for a collaborative problem, which involves working together with other healthcare professionals to address the issue. Interdependent interventions require collaboration and communication among healthcare team members to achieve the best outcomes for the patient.
Choice A (Dependent Nursing) refers to interventions that require an order from a healthcare provider.
Choice B (Independent) involves nursing actions that the nurse can initiate without the need for a healthcare provider's order.
Choice D (Physician-initiated) specifically denotes interventions initiated by a physician without direct involvement from the nurse.
In this case, the nurse's intervention for a collaborative problem aligns with the definition of interdependent intervention, making it the correct choice.