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At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse’s next action?
- A. Wait and change the dressing at 1800 as ordered. NursingStoreRN
- B. Revise the plan of care and change the dressing now.
- C. Reassess the dressing and the wound in 2 hours.
- D. Discontinue the plan of care for wound care.
Correct Answer: B
Rationale: The correct answer is B because a saturated and leaking dressing indicates a potential infection risk and compromised wound healing. The nurse should revise the plan of care and change the dressing immediately to prevent complications. Waiting until 1800 (choice A) could lead to further contamination and delay in treatment. Reassessing in 2 hours (choice C) might worsen the condition. Discontinuing the plan of care (choice D) is not appropriate without addressing the immediate issue.
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Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in nursing clinical decision-making. In this scenario, the nurse considers the patient's self-reported information (time of last dressing change and observation of old and new drainage) as key data points to validate the need for changing the wound dressing. This aligns with the principles of evidence-based practice and ensures that the decision is based on accurate and relevant information.
Choices B, C, and D are incorrect because they do not involve the systematic validation of data to inform the nursing decision-making process. Choice B relies on family input rather than objective data, Choice C jumps to a treatment decision without confirming the underlying cause, and Choice D does not involve validating the patient's reported symptom before taking action.
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. Problem statement
- B. Defining characteristics
- C. Etiology of the problem
- D. Outcomes criteria
Correct Answer: C
Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem.
Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.
A patient tells his nurse that he has delayed having TURP because he is afraid it will affect his sexual function. Which response by the nurse is most appropriate?
- A. “Don’t worry about sterility; sperm production is not affected by this surgery.”
- B. “Would you like some information about implants used for impotence?”
- C. “This type of surgery rarely affects the ability to have an erection or ejaculation.”
- D. “There are many methods of sexual expression that are alternatives to sexual intercourse.”
Correct Answer: C
Rationale: The correct answer is C: “This type of surgery rarely affects the ability to have an erection or ejaculation.” This response is appropriate because it provides accurate information that addresses the patient's concern about sexual function without making any false claims. TURP (Transurethral Resection of the Prostate) typically does not impact a patient's ability to have an erection or ejaculate. This reassurance can help alleviate the patient's fears and provide him with accurate information to make an informed decision.
Explanation for why the other choices are incorrect:
A: “Don’t worry about sterility; sperm production is not affected by this surgery.” - This is incorrect as the concern is more about sexual function than sterility.
B: “Would you like some information about implants used for impotence?” - This is incorrect as it jumps to a solution without addressing the patient's specific concern about TURP affecting sexual function.
D: “There are many methods of sexual expression that are alternatives to sexual intercourse
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: B
Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.
The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.