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In planning for Jose's oxygen therapy, the nurse shall consider which of the following, EXCEPT
- A. need for a humidifier.
- B. length of tubing.
- C. determine the age of Jose.
- D. manner of administering oxygen, continuous or intermittent.
Correct Answer: C
Rationale: When planning for Jose's oxygen therapy, the nurse should consider the need for a humidifier to prevent drying of the mucous membranes, the appropriate length of tubing for mobility and safety reasons, and the manner of administering oxygen (continuous or intermittent) based on Jose's condition and oxygen requirements. However, determining Jose's age is not a relevant factor in planning for his oxygen therapy. The decision-making process should be based on his specific medical needs and condition rather than his age.
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The APPROPRIATE nursing diagnosis to protect the patient from further injury is, which of the following?
- A. Altered mucous membrane related to chemotherapy.
- B. Interrupted family processes related to life threatening i1lness of a family member.
- C. Fatigue related to disease process.
- D. Risk for injury related to thrombocytopenia
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.
Which criterion refers-to the ability of the instrument to detect fine differences among the subjects being studied?
- A. Reliability
- B. objectivity
- C. Sensitivity
- D. Validity
Correct Answer: C
Rationale: Sensitivity refers to the ability of an instrument to detect small or fine differences among the subjects being studied. In the context of research or measurement tools, sensitivity is crucial for identifying subtle variations in the data that may hold importance in the analysis. A sensitive instrument can accurately measure and record even the smallest changes, making it a valuable criterion when assessing the quality of a measurement tool in research studies. High sensitivity indicates that the instrument is more likely to pick up on nuances and variations in the data, providing researchers with more detailed and accurate information to work with.
A patient presents with urinary frequency, urgency, dysuria, and suprapubic pain. Urinalysis reveals pyuria and bacteriuria. Which of the following conditions is most likely?
- A. Acute glomerulonephritis
- B. Chronic kidney disease
- C. Urinary tract infection (UTI)
- D. Renal calculi
Correct Answer: C
Rationale: The patient's presentation of urinary frequency, urgency, dysuria, and suprapubic pain along with the urinalysis findings of pyuria (pus in the urine) and bacteriuria (bacteria in the urine) are highly suggestive of a urinary tract infection (UTI). UTIs are one of the most common types of bacterial infections seen in clinical practice. The symptoms described are classic for a lower urinary tract infection. The presence of pyuria and bacteriuria on urinalysis further supports the diagnosis of a UTI. Acute glomerulonephritis typically presents with hematuria, proteinuria, hypertension, and edema. Chronic kidney disease is often asymptomatic in early stages and presents with symptoms like fatigue, edema, and changes in urination later on. Renal calculi are associated with severe colicky flank pain that can radiate to the groin, and they may present with
A patient with a history of coronary artery disease is scheduled for coronary artery bypass graft (CABG) surgery. Which preoperative nursing intervention is essential for preparing the patient for surgery?
- A. Administering aspirin to prevent thrombosis
- B. Providing education about postoperative pain management
- C. Assisting the patient with deep breathing and coughing exercises
- D. Obtaining informed consent for the surgical procedure
Correct Answer: C
Rationale: Preoperative nursing intervention that is essential for preparing a patient with a history of coronary artery disease for coronary artery bypass graft (CABG) surgery is assisting the patient with deep breathing and coughing exercises. These exercises are crucial to prevent postoperative complications such as atelectasis and pneumonia, which are common risks after surgery. Deep breathing exercises help to expand the lungs and improve ventilation, while coughing exercises help to clear secretions and prevent respiratory complications. By assisting the patient with these exercises preoperatively, the nurse can help optimize the patient's respiratory function and decrease the risk of complications during and after surgery. Administering aspirin, providing education about pain management, and obtaining informed consent are also important aspects of preoperative care, but assisting with deep breathing and coughing exercises is particularly essential for patients undergoing CABG surgery due to the increased risk of respiratory complications in this population.
Nurse Cris received information from some community residents who suspect that a neighbor ls abusing his young child. Which should be the PRIORITY nursing action ?
- A. Report the police authorities.
- B. Notify the social worker.
- C. Ignore the information
- D. Validate the information
Correct Answer: A
Rationale: The PRIORITY nursing action when receiving information about suspected child abuse is to report to the police authorities. Child abuse is a serious issue that requires immediate intervention to ensure the safety and well-being of the child. The police are trained to investigate these types of situations and can take the necessary steps to protect the child from harm. It is essential to act swiftly and report any suspicions of child abuse to the proper authorities to prevent further harm and ensure the child's safety.