Nokea
After admission for elective surgery, an adult says to the nurse, 'They asked me if I had advance directives. I don't even know what that is.' What is the best response by the nurse?
- A. Advance directives are usually written by persons who have a terminal illness. They are not indicated for elective surgery.
- B. An advance directive is a document that tells the medical and nursing staff what your wishes are regarding certain health care items should you not be able to make decisions for yourself.
- C. An advance directive includes information about you and your specific medical history that could be important to care givers if you are not alert.
- D. Advance directives direct your family about your plans for distributing your belongings when you are no longer here.
Correct Answer: B
Rationale: Advance directives specify healthcare preferences for incapacitation, relevant for any adult, clearly explaining their purpose.
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A client with an acute attack of gout is started on colchicines (Colorys). She should be instructed to report which of the following symptoms?
- A. Diarrhea
- B. Headache
- C. Itching
- D. Fever
Correct Answer: A
Rationale: Colchicine commonly causes diarrhea, which should be reported to prevent dehydration or other complications.
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment.
- A. What should the nurse do if the patient’s left leg is externally rotated?
- B. Place a trochanter roll on the outer aspect of the thigh.
- C. Perform resistive range of motion of the left leg.
- D. Adduct and internally rotate the left leg.
- E. Instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: A trochanter roll placed on the outer aspect of the thigh prevents external rotation by holding the hip in a neutral position and maintaining normal leg alignment. Resistive exercises, manual repositioning, or instructing the patient to maintain position are less effective, as they do not provide sustained support to prevent rotation.
A nine-year-old client with an ostomy.
Which of the following statements, if made by the parents of a nine-year-old client with an ostomy, would indicate to the nurse that they are providing quality home care?
- A. We change the bag at least once a week, and we carefully inspect the stoma at that time.'
- B. We change the bag every day so that we can inspect the stoma and the skin.'
- C. We encourage our daughter to watch TV while we change her ostomy bag.'
- D. We only have to change the ostomy bag every ten days.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-ostomy bags should be changed at least once a week; good time for stoma to be closely inspected (2) bag should be changed at least once a week or when seal around stoma is loose or leaking (3) does not encourage client participation or foster independence (4) bag should be changed more often
A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client has received 80 mg of furosemide (Lasix).
Which of the following nursing observations is MOST important to report to the next shift?
- A. Complaints of nausea and vomiting.
- B. Urine output of 200 cc in 2 hours.
- C. Quiet and withdrawn behavior after lunch.
- D. Blood pressure changes from 160/90 to 150/90.
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read the answers for clues. (1) further signs and symptoms of right-sided heart failure; not a priority (2) correct-furosemide is diuretic, which warrants close observation of the client's urine output (3) further signs and symptoms of right-sided heart failure; not a priority (4) may occur as a result of volume loss, but is not a priority over answer choice #2
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client.
Before administering this drug, the nurse should
- A. check for known allergies to medications.
- B. ensure that the client's respiratory rate is over 12.
- C. administer dexamethasone sodium phosphate (Decadron) 2 mg IV stat.
- D. check the client's blood pressure both sitting and standing.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-assessment, piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) assessment, not relevant for administration of this medication (3) implementation, not relevant for administration of this medication (4) assessment, not relevant for administration of this medication