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After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: The correct answer is C because it is essential for the nurse to ensure accurate and up-to-date vital signs before administering medications. By asking the NAP to record the patient's vital signs, the nurse can make informed decisions about the patient's condition and prevent any potential complications.
Choice A is incorrect because administering medications without knowing the patient's vital signs, particularly if they are abnormal, can be dangerous. Choice B is not the best course of action as it delays the crucial step of obtaining the vital signs. Choice D is incorrect as omitting vital signs without assessment could compromise patient safety. Therefore, choice C is the most appropriate response to ensure patient well-being and medication safety.
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As part of primary cancer prevention program, an oncology nurse answers questions from the public at health fair. When someone asks about the laryngeal cancer, the nurse should explain that:
- A. Laryngeal cancer is one of the most preventable types of cancer
- B. Inhaling polluted air isn’t a risk factor for laryngeal cancer
- C. Laryngeal cancer occurs primarily in women
- D. Adenocarcinoma accounts for most cases of laryngeal cancer
Correct Answer: A
Rationale: The correct answer is A: Laryngeal cancer is one of the most preventable types of cancer. This is because the primary risk factors for laryngeal cancer are largely related to lifestyle choices such as smoking, excessive alcohol consumption, and exposure to certain occupational hazards. By avoiding these risk factors, individuals can significantly reduce their chances of developing laryngeal cancer.
Choices B, C, and D are incorrect:
B: Inhaling polluted air isn’t a risk factor for laryngeal cancer - This is incorrect as exposure to polluted air can contribute to the development of laryngeal cancer.
C: Laryngeal cancer occurs primarily in women - This is incorrect as laryngeal cancer occurs more frequently in men than in women.
D: Adenocarcinoma accounts for most cases of laryngeal cancer - This is incorrect as squamous cell carcinoma is the most common type of laryngeal cancer, not adenocarcin
During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:
- A. Enzyme-linked immunosuppressant assay
- B. Stool for Clostridium difficile test
- C. Flat palate X-ray of the abdomen
- D. Electrolyte panel and hemogram
Correct Answer: B
Rationale: The correct answer is B: Stool for Clostridium difficile test. In this scenario, the client is experiencing symptoms suggestive of a possible Clostridium difficile infection, a common complication of chemotherapy. The test is crucial to confirm the presence of C. difficile toxins in the stool, which would guide appropriate treatment with antibiotics such as metronidazole or vancomycin.
A: Enzyme-linked immunosuppressant assay is not relevant in this context as it is used to measure levels of immunosuppressant drugs, not for diagnosing C. difficile infection.
C: Flat palate X-ray of the abdomen is unnecessary and would not provide information about the cause of the symptoms.
D: Electrolyte panel and hemogram are important for monitoring overall health status but do not directly address the specific issue of possible C. difficile infection.
What is the primary purpose of validation as a part of assessment?
- A. To identify data to be validated
- B. To establish an effective nurse–client communication
- C. To maintain effective relationships with coworkers
- D. To plan appropriate nursing care
Correct Answer: D
Rationale: The primary purpose of validation in assessment is to ensure that the data collected is accurate and reliable to plan appropriate nursing care. Validation helps confirm the accuracy of data, identify inconsistencies, and ensure that the information gathered is trustworthy. By verifying the data, nurses can make informed decisions and tailor individualized care plans to meet the patient's needs effectively. Choices A, B, and C are incorrect because they do not directly relate to the purpose of validation in assessment. Choice A focuses on the identification of data, not the purpose of validation. Choice B and C pertain to communication and relationships, which are important but not the primary purpose of validation in the assessment process.
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
- A. Massage reddened areas with lotion or oils
- B. Use special water mattress
- C. Turn frequently every 2 hours
- D. Keep skin clean and dry
Correct Answer: C
Rationale: The correct answer is C: Turn frequently every 2 hours. This helps redistribute pressure, preventing constant pressure on one area and reducing the risk of developing pressure ulcers. Turning every 2 hours promotes circulation and relieves pressure points.
A: Massaging reddened areas can worsen the condition by increasing friction and pressure.
B: While a special water mattress can help in preventing pressure ulcers, turning frequently is more effective.
D: Keeping the skin clean and dry is important for overall skin health but may not directly prevent pressure ulcers.
What is an example of a nurse modifying the care plan during the evaluation phase?
- A. Adding a new intervention to address an unmet goal.
- B. Performing routine monitoring of the client’s condition.
- C. Administering medication as prescribed by the physician.
- D. Completing discharge paperwork for the client.
Correct Answer: A
Rationale: The correct answer is A because modifying the care plan during the evaluation phase involves making changes based on the client's response to interventions. By adding a new intervention to address an unmet goal, the nurse demonstrates critical thinking and adaptability in response to the client's needs. This action shows that the nurse is actively assessing and revising the care plan to ensure it is effective in meeting the client's goals.
Choice B is incorrect because routine monitoring is part of the assessment and implementation phases, not specifically related to modifying the care plan during evaluation. Choice C is incorrect as administering medication is part of the implementation phase and does not necessarily involve modifying the care plan. Choice D is also incorrect as completing discharge paperwork is typically part of the discharge planning phase, not the evaluation phase where modifications to the care plan are made based on client outcomes.