Nokea
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The correct answer is C: Acute pain. This is the most pertinent nursing diagnosis because the patient has a right femur fracture and reports moderate discomfort. The priority is to address the acute pain associated with the fracture. Posttrauma syndrome (A) typically involves a broader range of emotional and psychological responses beyond just moderate discomfort. Constipation (B) is not the priority in this case, as it is not directly related to the patient's current condition. Anxiety (D) may be present but addressing the acute pain takes precedence in this situation to ensure the patient's comfort and well-being.
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. During the first 24 hours after a client is diagnosed with Addisonian crisis, which of the following should the nurse perform frequently?
- A. Weigh the client.
- B. Administer oral hydrocortisone.
- C. Test urine for ketones.
- D. Assess vital signs.
Correct Answer: D
Rationale: The correct answer is D, assess vital signs, as it is crucial to monitor the client's hemodynamic stability and response to treatment during the critical initial 24 hours of Addisonian crisis. Vital signs such as blood pressure, heart rate, and respiratory rate provide valuable information about the client's condition and response to therapy. Weighing the client (choice A) and testing urine for ketones (choice C) may be important but not as immediately critical as monitoring vital signs. Administering oral hydrocortisone (choice B) is essential for treatment but does not require frequent administration within the first 24 hours.
Nursing intervention during the lumbar puncture procedure includes:
- A. Monitoring Mrs. GC’s color, pulse and respiration
- B. Labeling all laboratory specimens in numerical order
- C. Positioning Mrs. GC on her side with knees drawn up to her chest
- D. All of the above
Correct Answer: D
Rationale: Step 1: Monitoring Mrs. GC's color, pulse, and respiration is important to assess for any signs of distress during the procedure.
Step 2: Labeling all laboratory specimens in numerical order ensures accurate identification and prevents errors in specimen handling.
Step 3: Positioning Mrs. GC on her side with knees drawn up to her chest helps maintain proper spinal alignment and reduces the risk of complications.
Summary: Option D is correct because all the interventions mentioned are crucial for ensuring patient safety and procedural success. Options A, B, and C are incorrect individually as they each address only one aspect of the procedure, whereas the correct answer encompasses all necessary interventions.
Which is the most reliable method for monitoring fluid balance?
- A. Daily intake and output
- B. Vital signs
- C. Daily weight
- D. Skin turgor
Correct Answer: A
Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.
A patient understands the common causes of urinary tract infection if he or she states the following, EXCEPT:
- A. “UTI can be caused by holding the urge to urinate.”
- B. “Insertion of instruments and catheter to the urinary tract can introduce bacteria that can cause infection.”
- C. “I usually drink lots of water at night and it might have caused my UTI.”
- D. “UTI can be caused by unhygienic cleaning after defecation.”
Correct Answer: C
Rationale: Rationale: Choice C is the correct answer because drinking lots of water at night actually helps prevent UTIs by flushing out bacteria from the urinary tract. Holding the urge to urinate (Choice A) can increase the risk of UTIs as bacteria can multiply in stagnant urine. Insertion of instruments and catheters (Choice B) can introduce bacteria, leading to infection. Unhygienic cleaning after defecation (Choice D) can also introduce bacteria to the urinary tract, causing UTIs. Therefore, Choice C is the exception as it does not contribute to the common causes of UTIs.
When the nurse is reviewing a patient’s daily laboratory test results, which of the ff. electrolyte imbalances should the nurse recognize as predisposing the patient to digoxin toxicity?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: A
Rationale: Step-by-step rationale:
1. Digoxin toxicity can be potentiated by hypokalemia due to the risk of enhanced cardiac toxicity.
2. Hypokalemia can lead to increased sensitivity of cardiac cells to digoxin.
3. Low potassium levels can disrupt the sodium-potassium ATPase pump, enhancing digoxin's effects.
4. The nurse should recognize hypokalemia as a predisposing factor for digoxin toxicity.
Summary:
A: Hypokalemia is the correct answer as it enhances digoxin toxicity by affecting cardiac function.
B: Hyponatremia does not directly predispose to digoxin toxicity.
C: Hyperkalemia is not a predisposing factor and can actually counteract digoxin's effects.
D: Hypernatremia is not directly related to digoxin toxicity.