Nokea
Arthur, a 66-year old client for pneumonia has a temperature ranging from 39° to 40° C with periods of diaphoresis. Which of the following interventions by Nurse Carlos would be a priority?
- A. Administer oxygen therapy
- B. provide frequent linen changes
- C. provide fluid intake 3L/day
- D. maintain complete bed rest
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.
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A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect as it assumes the patient's fear is related to dressing changes, not discharge. Choice B is incorrect as resuming medications is not linked to the patient's fear of being alone. Choice D is incorrect as there is no indication in the scenario that the surgery was unsuccessful.
A client hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which of the following instructions would be most important to include in the client’s teaching plan?
- A. maintain a moderate exercise
- B. Lose weight
- C. Jog at least 2 miles per day
- D. Rest as much as possible
Correct Answer: A
Rationale: The correct answer is A: maintain a moderate exercise. Exercise helps in maintaining bone density, which is crucial in managing hyperparathyroidism. Moderate exercise can also help in weight management and overall health. Choice B, losing weight, can be helpful but not as crucial as exercise. Choice C, jogging 2 miles per day, may be excessive for some individuals and not necessary for managing hyperparathyroidism. Choice D, resting as much as possible, is not recommended as it can lead to muscle weakness and bone loss, which are already concerns in hyperparathyroidism.
A surgical intervention that can cause substantial remission of myasthenia gravis is:
- A. Esophagostomy
- B. Thymectomy
- C. Myomectomy
- D. Spleenectomy
Correct Answer: B
Rationale: The correct answer is B: Thymectomy. Thymectomy involves the surgical removal of the thymus gland, which is often abnormal in individuals with myasthenia gravis. The thymus plays a role in the development of the immune system and can contribute to the autoimmune response seen in myasthenia gravis. By removing the thymus gland, the autoimmune response may be reduced, leading to substantial remission of symptoms.
Choice A, Esophagostomy, involves creating a surgical opening into the esophagus and is not a treatment for myasthenia gravis. Choice C, Myomectomy, is the surgical removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, Spleenectomy, is the removal of the spleen and is not a standard treatment for myasthenia gravis.
A client is admitted to the hospital with a bleeding ulcer and is to receive 4 units of packed cells. Which nursing intervention is of primary importance in the administration of blood?
- A. Checking the flow rate
- B. Monitoring the vital signs
- C. Identifying the client
- D. Maintaining blood temperature
Correct Answer: C
Rationale: Step 1: Identifying the client is crucial for correct blood transfusion to avoid errors.
Step 2: Client identification includes verifying name, date of birth, and unique identifiers.
Step 3: Ensuring correct patient prevents transfusion reactions and improves patient safety.
Step 4: Monitoring vital signs and flow rate are important but secondary to client identification.
Step 5: Maintaining blood temperature is not a primary concern during blood transfusion.
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a cerebellar brain tumor can affect the client's coordination and balance due to its location in the brain responsible for fine motor movements. Impaired balance increases the risk for falls and injuries. Visual field deficits (choice A) may contribute to the risk of injury but not as directly as impaired balance. Difficulty swallowing (choice C) and psychomotor seizures (choice D) are not directly related to the client's risk for injury due to a cerebellar brain tumor.