Nokea
A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
- A. patients.” “If the nursing department uses this system, communication among nurses who work
- B. throughout the hospital may be enhanced.” “We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our
- C. unit.” “The NIC system provides one way to improve safe and effective documentation in the
- D. hospital’s electronic health record.”
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.
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Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
- A. Imbalanced nutrition:Less than body requirements related to poor intake
- B. Disturbed sleep pattern related to external stimuli
- C. Impaired skin integrity related to pruritus
- D. Pain related to sickle cell crisis
Correct Answer: D
Rationale: The correct answer is D: Pain related to sickle cell crisis. In a sickle cell crisis, the client experiences severe pain due to the sickling of red blood cells, which causes blockages in blood vessels. This pain is the hallmark symptom of sickle cell crisis and is a priority nursing diagnosis. The other choices are incorrect because they do not directly relate to the primary issue of sickle cell crisis. Imbalanced nutrition is not typically a priority during a crisis, disturbed sleep pattern is not a common symptom, and impaired skin integrity is not a prominent concern in sickle cell crisis.
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
- A. “Alcohol is not contraindicated while taking this medication.”
- B. “Good oral hygiene is needed, including brushing and flossing.”
- C. “The medication dose may be self-adjusted depending on side effects.”
- D. “The morning dose of the medication should be taken before a serum drug level is drawn.”
Correct Answer: B
Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect.
Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication.
Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm.
Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.
What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?
- A. Avoid showering for 1 week.
- B. Sleep in a semi-fowler’s position.
- C. Receive vaccines against infection.
- D. Stay on antibiotics for life.
Correct Answer: C
Rationale: The correct answer is C: Receive vaccines against infection. Following a splenectomy, the patient is at an increased risk of infection due to the absence of the spleen's immune function. Vaccines help boost the body's immunity against specific pathogens, reducing the risk of infections. This is crucial for preventing post-splenectomy infections.
Now, let's analyze the other choices:
A: Avoid showering for 1 week - There is no evidence to support that avoiding showering would prevent infection after a splenectomy.
B: Sleep in a semi-fowler’s position - Positioning does not directly impact infection prevention post-splenectomy.
D: Stay on antibiotics for life - Long-term antibiotic use can lead to antibiotic resistance and is not recommended unless specifically indicated for a different reason.
An African client has been diagnosed with Osteomyelitis. The nurse expects to assess which of the following?
- A. pale, cool, tender skin at site
- B. decreased white blood cell count
- C. positive wound cultures
- D. decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: The correct answer is C: positive wound cultures. Osteomyelitis is an infection of the bone that is typically diagnosed through wound cultures. This assessment helps to identify the causative organism and guide appropriate treatment. Choices A and D are not typical findings in osteomyelitis. Choice A describes symptoms of poor circulation which are not specific to osteomyelitis. Choice B, decreased white blood cell count, is typically not seen in the presence of an infection like osteomyelitis.
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.