Nokea
A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?
- A. Consult physical therapy.
- B. Establish a new plan of care.
- C. Set new priorities for the patient.
- D. Assess the patient.
Correct Answer: D
Rationale: The correct initial action to take after the patient falls is to assess the patient (Choice D). This is important to determine the extent of any injuries sustained, assess the patient's current condition, and identify any factors that may have contributed to the fall. By conducting a thorough assessment, the nurse can gather crucial information to inform the revision of the care plan. Consulting physical therapy (Choice A) may be necessary later on but is not the immediate priority. Establishing a new plan of care (Choice B) and setting new priorities (Choice C) should be based on the assessment findings, making Choice D the most appropriate initial action.
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Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. Administer 2 to 3L of IV fluid rapidly
- B. Administer 6L of IV fluid over the first 24 hours
- C. Administer a dextrose solution containing normal saline solution
- D. Administer IV fluid slowly to prevent circulatory overload and collapse
Correct Answer: B
Rationale: The correct answer is B: Administer 6L of IV fluid over the first 24 hours. In HHNS, dehydration is severe due to high blood glucose levels causing osmotic diuresis. Rapid infusion of fluid can lead to fluid overload and exacerbate the situation. Administering 6L over 24 hours helps gradually replenish lost fluids without causing circulatory overload. Choice A is incorrect because rapid infusion can lead to fluid overload. Choice C is incorrect because adding dextrose to the solution can further increase blood glucose levels. Choice D is incorrect because administering IV fluids slowly can delay rehydration in a critical situation like HHNS.
A nurse conducts an assessment and notes that the client has abnormal breath sounds, a productive cough, and cyanotic lips. How should the nurse categorize these findings?
- A. Subjective data
- B. Objective data
- C. Secondary data
- D. Primary data
Correct Answer: B
Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data.
Summary:
- A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse.
- C: Secondary data are information obtained from other sources, not directly from the client.
- D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
- A. Risk for increased cardiac output related to fluid volume excess
- B. Disturbed sensory perception related to bleeding into tissues
- C. Alteration in tissue perfusion related to bleeding and diminished blood flow
- D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C
Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues.
Explanation:
1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output.
2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception.
3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body.
In summary, the correct answer is C because DIC can lead to altered tissue perfusion
To combat the most common adverse effects of chemotherapy, the nurse would administer an:
- A. Antiemetic
- B. Antibiotic
- C. Antimetabolite
- D. Anticoagulant
Correct Answer: A
Rationale: The correct answer is A: Antiemetic. Chemotherapy commonly causes nausea and vomiting as adverse effects. Antiemetics are medications specifically designed to prevent or alleviate nausea and vomiting. Administering an antiemetic helps manage these side effects and improve the patient's quality of life during chemotherapy. Antibiotics (B) are used to treat bacterial infections, not chemotherapy side effects. Antimetabolites (C) are a type of chemotherapy drug, not used to combat its side effects. Anticoagulants (D) are used to prevent blood clots and are not indicated for managing chemotherapy side effects like nausea and vomiting.
Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
- A. Hyperventilating James with 100% oxygen before and after suctioning
- B. Instilling 3 to 5 ml normal saline to loosen up secretion
- C. Applying suction during catheter withdrawal
- D. Suction the client every hour
Correct Answer: A
Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows:
1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity.
2. Oxygen toxicity can result in lung damage and other complications.
3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations.
Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.