Nokea
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
- A. Hand bell and extra bed linen
- B. Footboard and splint
- C. Sandbag and trochanter rolls
- D. Suction machine and gloves
Correct Answer: C
Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning.
Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation.
Step 3: These help prevent pressure ulcers and maintain proper body alignment.
Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care.
Step 5: Footboard and splint may not be relevant to his specific condition.
Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco.
Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.
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A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs.
A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations.
C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences.
D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.
Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:
- A. respiratory compromise related to inhalation of smoke
- B. pneumonia related to prolonged bedrest
- C. fat embolism syndrome related to femur fracture
- D. hypovolemic shock related to multiple trauma
Correct Answer: C
Rationale: The correct answer is C: fat embolism syndrome related to femur fracture. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress. In this case, the patient's femur fracture likely led to fat embolism, explaining her dyspnea, tachypnea, crackles, and thick sputum. Choices A, B, and D do not align with the patient's presentation and history, making them incorrect. Choice A suggests smoke inhalation, which is not supported by the scenario. Choice B mentions pneumonia from bedrest, which is not a common complication of immobility. Choice D proposes hypovolemic shock from multiple trauma, which does not explain the respiratory symptoms and sputum production observed in the patient.
Which laboratory study is monitored for the patient receiving heparin therapy?
- A. INR
- B. PTT
- C. PT
- D. Bleeding time
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect.
A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin.
C: PT (Prothrombin Time) is also used to monitor warfarin therapy.
D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?
- A. “If the man appears clean and has been conscientious about using condoms, he is likely infection free.”
- B. “Look carefully for signs of lesions before engaging in sexual activity.”
- C. “Be sure to use either a male or female condom to protect against possible transmission of infection.”
- D. “An examination by a physician with diagnostic testing is the only way to know if he is infection free.”
Correct Answer: D
Rationale: Step 1: The correct answer is D because it emphasizes the importance of medical examination and diagnostic testing to determine if the man has an STD.
Step 2: Visual inspection (choice B) is not reliable as some STDs may not present with visible symptoms.
Step 3: Relying solely on appearance and condom use (choices A and C) does not guarantee protection against all STDs.
Step 4: Choice D is the best option as it advocates for seeking professional medical advice for accurate diagnosis and treatment.
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
- A. The written outcomes are designed to meet nursing goals
- B. To encourage the client and family to be involved
- C. To discourage additions by other healthcare providers
- D. Why the nurse believes the outcome is important
Correct Answer: B
Rationale: The correct answer is B because involving the client and family in developing outcomes promotes patient-centered care and increases the likelihood of achieving successful outcomes. This approach fosters collaboration, shared decision-making, and empowers the client and family in their own care. It also helps to ensure that the outcomes align with the client's values, preferences, and goals. Choices A, C, and D are incorrect because focusing solely on nursing goals without considering the client's perspective may lead to a lack of engagement and poor outcomes. Discouraging input from other healthcare providers limits the interdisciplinary approach to care, and focusing on why the nurse believes the outcome is important neglects the client's role in the decision-making process.