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If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?
- A. Left atrial atrophy
- B. Left ventricular hypertrophy
- C. Right atrial atrophy
- D. Right ventricular hypertrophy
Correct Answer: D
Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.
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The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?
- A. Staff documentation of turning the patient every 2 hours
- B. Presence of redness only on the heels of the patient
- C. Patient’s eating 100% of all meals NursingStoreRN
- D. Absence of skin breakdown
Correct Answer: D
Rationale: The correct answer is D because the absence of skin breakdown indicates that the turning schedule was effective in preventing pressure ulcers. Skin breakdown is a key indicator of pressure ulcer development, so its absence suggests that the patient's skin integrity was maintained. Choice A is incorrect because documentation alone does not guarantee successful prevention. Choice B is incorrect as redness on the heels can still indicate the early stages of pressure ulcers. Choice C is unrelated to skin integrity and pressure ulcer prevention.
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
- A. “Keep the stoma uncovered.”
- B. “Keep the stoma dry.”
- C. “Have a family member perform stoma care initially until you get used to the procedure.”
- D. “Keep the stoma moist.”
Correct Answer: B
Rationale: The correct answer is B: "Keep the stoma dry." Keeping the stoma dry helps prevent infection and skin irritation. Moisture can lead to fungal growth and skin breakdown. Option A is incorrect because keeping the stoma uncovered can increase the risk of contamination and infection. Option C is incorrect as self-care promotes independence and allows the client to become familiar with the procedure. Option D is incorrect as moisture can lead to skin issues.
Mr. RR is to have a brain scanning. Nursing intervention in preparation for this test includes:
- A. Discontinuing any anticonvulsant therapy
- B. Obtaining consent for the treatment
- C. Explaining to Mr. RR that although his head will be supported in place for a period of time, the test will not be painful.
- D. Informing Mr. RR that nausea and headache are frequent following this test
Correct Answer: C
Rationale: The correct answer is C because it addresses the specific nursing intervention needed to prepare Mr. RR for the brain scanning test. By explaining to Mr. RR that the test will not be painful and that his head will be supported in place, the nurse helps alleviate any potential anxiety or fear he may have. This information reassures the patient and ensures his cooperation during the procedure.
Choice A is incorrect because discontinuing anticonvulsant therapy without medical approval could have serious consequences for Mr. RR's health. Choice B is also incorrect as obtaining consent is important, but it is not directly related to preparing Mr. RR for the test. Choice D is incorrect as it introduces potential negative outcomes without providing necessary information to prepare the patient for the test.
A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?
- A. Act as a leader of the health care team.
- B. Develop good communication skills.
- C. Work solely with nurses.
- D. Avoid conflict.
Correct Answer: B
Rationale: The correct answer is B: Develop good communication skills. In interdisciplinary collaboration, effective communication is essential for teamwork. By developing good communication skills, the nurse can effectively interact with other healthcare professionals to provide holistic care. Choice A is incorrect as the nurse should collaborate as part of a team, not necessarily be the leader. Choice C is incorrect as interdisciplinary collaboration involves working with professionals from various disciplines. Choice D is incorrect as conflict resolution is an important aspect of effective collaboration.
Which client has the highest risk of ovarian cancer?
- A. 30-year old woman taking contraceptives
- B. 45-year old woman who has never been pregnant
- C. 40-year old woman with three children
- D. 36-year old woman who had her first child at age 22
Correct Answer: B
Rationale: The correct answer is B: 45-year old woman who has never been pregnant. This client has the highest risk of ovarian cancer due to nulliparity, which is a known risk factor. Women who have never been pregnant have a higher risk of developing ovarian cancer compared to those who have had children. Other choices are incorrect because contraceptives actually reduce the risk of ovarian cancer, having children can slightly decrease the risk, and having a child at a young age does not increase the risk significantly.