Nokea
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient’s headache. Which action by the nurse is priority for this patient?
- A. Eliminate headache from the nursing care plan.
- B. Direct the nursing assistive personnel to ask if the headache is relieved.
- C. Reassess the patient’s pain level in 30 minutes.
- D. Revise the plan of care.
Correct Answer: C
Rationale: The correct answer is C: Reassess the patient's pain level in 30 minutes. This is the priority action as it allows the nurse to evaluate the effectiveness of the acetaminophen in relieving the patient's headache. By reassessing the pain level, the nurse can determine if the medication is working or if further intervention is needed.
A: Eliminating the headache from the care plan is not appropriate as the patient's comfort and pain relief should be a priority.
B: Directing the nursing assistive personnel to inquire if the headache is relieved is not thorough assessment and does not provide direct evaluation of the patient's pain level.
D: Revising the plan of care may be necessary based on the reassessment, but it is not the immediate priority compared to evaluating the patient's response to treatment.
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The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
- A. Diagnosis
- B. Planning NursingStoreRN
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning signs such as not voiding for over 8 hours, abnormal kidney function, and decreased oral intake, the nurse must move to the diagnosis step. In this step, the nurse will analyze the data collected to identify the patient's actual and potential health problems. This will help the nurse formulate appropriate nursing diagnoses and develop a plan of care to address the identified issues.
Choice B (Planning) comes after the diagnosis step, where specific goals and interventions are established; Choice C (Implementation) follows planning and involves executing the planned interventions; Choice D (Evaluation) is the final step where the nurse assesses the effectiveness of the interventions. In this scenario, the nurse must first determine the patient's health problems before proceeding to planning, implementing, and evaluating care.
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
- A. Cough as the cuff is being deflated
- B. Take a deep breath as the nurse deflates the cuff
- C. Hold the breath as the cuff is being re-inflated
- D. Exhale deeply as the nurse re-inflates the cuff
Correct Answer: B
Rationale: The correct answer is B: Take a deep breath as the nurse deflates the cuff. This is the correct choice because asking the client to take a deep breath while the cuff is deflated helps prevent aspiration of secretions into the lower airway. When the cuff is deflated, the tracheostomy tube provides a direct pathway for secretions to travel upwards, and taking a deep breath facilitates the movement of secretions out of the trachea.
Choice A (Cough as the cuff is being deflated) is incorrect because coughing while the cuff is being deflated can increase the risk of aspiration as secretions may be forced into the lower airway.
Choice C (Hold the breath as the cuff is being re-inflated) is incorrect as holding the breath while the cuff is being re-inflated can hinder the clearance of secretions from the trachea.
Choice D (Exhale deeply as the nurse re-inflates the cuff) is incorrect
An elderly nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?
- A. Hyponatremia
- B. Hypercalcemia
- C. Hyperkalemia
- D. Hypomagnesemia
Correct Answer: D
Rationale: The correct answer is D: Hypomagnesemia. Dehydration can lead to electrolyte imbalances, and hypomagnesemia can cause confusion in elderly patients. Magnesium plays a crucial role in brain function and its deficiency can result in cognitive impairment. Hyponatremia (A) typically presents with symptoms like weakness and confusion but not necessarily dehydration. Hypercalcemia (B) and hyperkalemia (C) are less likely to cause confusion in this scenario. Therefore, hypomagnesemia is the most likely electrolyte imbalance involved in the elderly nursing home resident's confusion.
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
- A. Blood pressure apparatus
- B. IV infusion stand
- C. Call bell
- D. Endotracheal intubation
Correct Answer: A
Rationale: Rationale:
1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty.
2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring.
3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care.
4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care.
Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.
When teaching a client about insulin administration, the nurse should include which instruction?
- A. “Administer insulin after the first meal of the day.”
- B. “Inject insulin at a 45-degree angle into the deltoid muscle.”
- C. “Shake the insulin vial vigorously before withdrawing the medication.”
- D. “Draw up clear insulin first when mixing two types of insulin in one syringe.”
Correct Answer: D
Rationale: The correct answer is D because drawing up clear insulin first when mixing two types of insulin in one syringe prevents contamination. Clear insulin is drawn up first to avoid clouding from the cloudy insulin. This ensures accurate dosing and prevents potential medication errors.
A: Incorrect. Administering insulin after the first meal may lead to hypoglycemia if the client skips or delays meals.
B: Incorrect. Insulin should not be injected into the deltoid muscle as it can lead to inconsistent absorption rates.
C: Incorrect. Vigorously shaking the insulin vial can cause bubbles, affecting the accuracy of the dose and potentially altering its effectiveness.