Determining whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: A
Rationale: The correct answer is A: Evaluation. Evaluation involves assessing the appropriateness and effectiveness of care provided to the patient. It helps determine if the care aligns with the patient's current physiological and psychological status. Choice B, Planning, refers to developing a plan of care based on assessment data. Choice C, Implementation, involves carrying out the planned interventions. Choice D, Assessment, is the initial step that involves collecting data about the patient's condition.
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The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?
- A. Presence of thin pink drainage in the Jackson Pratt
- B. Guarding when the nurse touches the abdomen
- C. Tenderness around the surgical site during palpation
- D. Complaints of chills and feeling feverish
Correct Answer: D
Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.
The nurse is caring for clients on a medical floor. Which client will the nurse assess first?
- A. The client with an abdominal aortic aneurysm who is constipated
- B. The client on bed rest who ambulated to the bathroom
- C. The client with essential hypertension who has epistaxis and a headache
- D. The client with arterial occlusive disease who has a decreased pedal pulse
Correct Answer: C
Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis that necessitate immediate intervention. Choice A is incorrect as constipation in a client with an abdominal aortic aneurysm, while important, does not indicate an immediate crisis. Choice B is incorrect as a client on bed rest ambulating to the bathroom is a positive sign. Choice D is incorrect because a decreased pedal pulse in arterial occlusive disease should be addressed promptly, but it does not indicate an acute emergency like a hypertensive crisis.
During a physical assessment of a newborn, which of the following findings should the nurse prioritize reporting?
- A. Head circumference of 40 cm
- B. Chest circumference of 32 cm
- C. Acrocyanosis and edema of the scalp
- D. Heart rate of 160 bpm and respirations of 40/min
Correct Answer: A
Rationale: The correct answer is A. A head circumference of 40 cm is abnormally large for a newborn and could indicate conditions like hydrocephalus or other abnormalities, making it a crucial finding to report. Choices B, C, and D are within normal parameters for a newborn and do not pose immediate concerns. Chest circumference of 32 cm is a normal finding. Acrocyanosis and edema of the scalp are common in newborns due to physiological adaptations. A heart rate of 160 bpm and respirations of 40/min may be within the normal range for a newborn.
A patient with a history of gout should avoid which type of food?
- A. Red meat
- B. Chicken
- C. Fish
- D. Dairy
Correct Answer: A
Rationale: A patient with a history of gout should avoid foods high in purines, which can exacerbate gout attacks. Red meat is particularly high in purines, so it is the type of food that should be avoided. Chicken and fish are lower in purines compared to red meat, making them better choices for individuals with gout. Dairy products are generally not associated with triggering gout attacks, so they can be consumed in moderation by patients with gout.
The nurse on the postsurgical unit received a client who was transferred from the post-anesthesia care unit (PACU) and is planning care for this client. The nurse understands that staff should begin planning for this client's discharge at which point during the hospitalization?
- A. Is admitted to the surgical unit
- B. Is transferred from the PACU to the postsurgical unit
- C. Is able to perform activities of daily living independently
- D. Has been assessed by the healthcare provider for the first time after surgery
Correct Answer: A
Rationale: Discharge planning should begin as soon as the patient is admitted to the surgical unit to ensure a smooth transition. It is important to start early to address any potential barriers to discharge, coordinate resources, and provide adequate education and support. Choices B, C, and D are not the appropriate points to start discharge planning as they do not mark the beginning of the hospitalization phase related to the surgical unit.