Nokea
Aling Iska, a 78-year old client consults with a hemoglobin and hematocrit levels of 11mg/dl and 32 % respectively. These finding indicates:
- A. nothing because these are normal findings
- B. the nurse should conduct a thorough nutritional assessment
- C. understanding that the client should be advised to have the test repeated in three months
- D. understanding that anemia is a part of the degeneration of the bone marrow
Correct Answer: B
Rationale: Rationale: Answer B is correct because a hemoglobin level of 11mg/dl and hematocrit level of 32% in a 78-year-old client are indicative of anemia. Conducting a thorough nutritional assessment is essential to identify potential causes of anemia such as iron deficiency or vitamin deficiencies. This assessment will help determine appropriate interventions to manage the anemia.
Summary:
A: Incorrect. These levels are indicative of anemia, not normal findings.
C: Incorrect. Advising to repeat the test in three months may delay necessary interventions for the anemia.
D: Incorrect. While anemia can be related to bone marrow degeneration, a nutritional assessment is needed to identify the specific cause in this case.
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A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.
Which of the ff nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver
- B. Encourage the client to perform exercises
- C. Assess apical heart before administering digitalis
- D. Offer small frequent feedings
Correct Answer: C
Rationale: The correct answer is C: Assess apical heart before administering digitalis. This is important because digitalis can slow down the heart rate, so it is crucial to monitor the client's heart rate before giving the medication to prevent further decrease in cardiac output. Encouraging activities that engage the Valsalva maneuver (A) is contraindicated in clients with congestive heart failure as it can lead to increased intra-thoracic pressure and decreased venous return, worsening cardiac output. Encouraging the client to perform exercises (B) may also increase cardiac workload and exacerbate symptoms. Offering small frequent feedings (D) is generally beneficial for clients with congestive heart failure to prevent overeating and promote easier digestion, but it does not directly address the decreased cardiac output concern in this scenario.
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
- A. Fluid intake of less than 2,500mL
- B. Blood pressure of 90/50mmHg
- C. Pulse rate of 126 beats/min
- D. Urine output of more than 200mL/hour
Correct Answer: A
Rationale: The correct answer is A: Fluid intake of less than 2,500mL. In diabetes insipidus, the body cannot properly regulate fluid balance, leading to excessive thirst and urination. Successful treatment aims to manage these symptoms by reducing fluid intake to prevent dehydration. Therefore, a decrease in fluid intake indicates successful treatment.
Explanation for incorrect choices:
B: Blood pressure of 90/50mmHg - Blood pressure is not directly related to the treatment of diabetes insipidus.
C: Pulse rate of 126 beats/min - Pulse rate is not a specific indicator of successful treatment for diabetes insipidus.
D: Urine output of more than 200mL/hour - In diabetes insipidus, excessive urine output is a symptom of the condition, so an increase in urine output does not indicate successful treatment.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because it is important for the nurse to communicate directly with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter may undermine the patient's autonomy and dignity. It is crucial for the nurse to establish rapport and build a therapeutic relationship with the patient. Making eye contact with the patient (choice A) is a good nonverbal communication technique. Leaning forward while talking with the patient (choice C) shows attentiveness and engagement. Nodding periodically while the patient is speaking (choice D) demonstrates active listening and encourages the patient to continue sharing. However, speaking only to the patient's daughter (choice B) is the incorrect choice as it neglects the patient's role in the conversation and may lead to potential issues in communication and patient-centered care.
The physician orders furosemide (Lasix) 40 mg IV STAT for an acutely fluid-overloaded patient. Why was the IV route likely chosen?
- A. Furosemide can be administered only by the IV route.
- B. IV is the route of choice for rapid administration.
- C. IV dosing is more accurate.
- D. IV furosemide has a fewer side effects than oral.
Correct Answer: B
Rationale: The correct answer is B: IV is the route of choice for rapid administration. IV route allows for quick onset of action, crucial in acutely fluid-overloaded patients needing immediate diuresis. Option A is incorrect as furosemide can be given orally too. Option C is less relevant in this urgent situation where speed is key. Option D is also incorrect as the side effects are not determined by route of administration.