Nokea
An adult has and IV line in the right forearm infusing D5 ½ NS with 20 mEq of potassium at 75 ml/h. which statement would be a correct report from the RN?
- A. The potassium bag is piggybacked into the dextrose at 75ml/h
- B. The clamp should be closed below the D5 ½ NS bag
- C. Potassium is on the secondary line
- D. 75 ml infuse in one hour
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Potassium is typically administered on a secondary line to prevent rapid infusion and potential adverse effects.
2. The primary line carries the D5 ½ NS solution without potassium, while the secondary line delivers the potassium.
3. Reporting that "potassium is on the secondary line" accurately describes the setup for this IV infusion.
Summary:
A: Incorrect - Incorrectly states that the potassium bag is piggybacked into the dextrose.
B: Incorrect - Closing the clamp below the D5 ½ NS bag is unnecessary and does not address the potassium infusion.
D: Incorrect - Fails to address the specific issue of the potassium infusion being on a secondary line.
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Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather comprehensive data about the patient's health status, including vital signs, physical appearance, and potential health issues. It provides valuable information for developing an individualized care plan. Reviewing literature (A) is important but not for establishing a patient's database. Checking orders (B) and ordering medications (D) are part of the treatment process and do not directly contribute to establishing the initial patient database.
A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
- A. Assigning clinical cues
- B. Defining characteristics
- C. Diagnostic reasoning NursingStoreRN
- D. Diagnostic labeling
Correct Answer: C
Rationale: The correct answer is C: Diagnostic reasoning. The nurse is utilizing assessment data to analyze and interpret the information to develop a nursing diagnosis. This involves critical thinking skills to make conclusions and create a plan of care.
A: Assigning clinical cues - This choice is incorrect as it refers to identifying objective and subjective data during assessment, not the process of analyzing and synthesizing data to form a diagnosis.
B: Defining characteristics - This choice is incorrect as it typically refers to the specific manifestations or symptoms associated with a particular nursing diagnosis, not the process of diagnosing itself.
D: Diagnostic labeling - This choice is incorrect as it refers to the final step in the nursing diagnosis process where the nurse assigns a label to the identified problem, not the overall process of diagnostic reasoning.
The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
- A. Begin a program of aggressive, strict mouth care
- B. Avoid traumatic injuries and exposure to any infection
- C. increase oral fluid intake to a minimum of 3000 ml daily
- D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B
Rationale: The correct answer is B - Avoid traumatic injuries and exposure to any infection. For a client with pancytopenia caused by chemotherapy, their immune system is compromised, making them more susceptible to infections and bleeding. By avoiding traumatic injuries and exposure to infections, the client can reduce the risk of complications. Option A is incorrect because aggressive mouth care may further damage the already compromised oral mucosa. Option C is incorrect because excessive fluid intake may not be necessary and could worsen electrolyte imbalances. Option D is incorrect because muscle cramps and tingling sensations are not directly related to the main concern of infection and bleeding in pancytopenia.
Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?
- A. How do I best cluster these data and cues to identify problems?
- B. What problems require my immediate attention or that of the team?
- C. What major defining characteristics are present for a nursing diagnosis?
- D. How do I document care accurately and legally?
Correct Answer: B
Rationale: The correct answer is B because during outcome identification and planning, it is crucial to prioritize problems that require immediate attention to ensure patient safety and well-being. By asking what problems need immediate attention, nurses can focus on addressing urgent issues first. Choice A focuses on data clustering for problem identification, choice C is related to defining characteristics for nursing diagnoses, and choice D pertains to documentation, which are important but not directly related to prioritizing immediate problems.
A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention?
- A. The patient will ambulate in the hallway twice this shift using crutches correctly.
- B. Impaired physical mobility related to inability to bear weight on right leg. Provide assistance while the patient walks in the hallway twice this shift with
- C. crutches.
- D. The patient is unable to bear weight on right lower extremity.
Correct Answer:
Rationale: Correct Answer: A: The patient will ambulate in the hallway twice this shift using crutches correctly.
Rationale:
1. This choice outlines a specific nursing intervention - ambulating with crutches.
2. It includes clear actions for the patient to ambulate and specifies using crutches correctly.
3. It addresses the patient's physical mobility needs actively.
4. It focuses on promoting independence and functional ability.
Summary of other choices:
B: This choice includes the nursing diagnosis and the plan but lacks the specificity of the correct answer.
C: This choice includes the nursing diagnosis and specifies the use of crutches but lacks the clarity of correct implementation.
D: This choice only identifies the patient's condition without providing a specific nursing intervention.