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Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
- A. Antibiotics as needed
- B. Bedrest
- C. Elevate the head of bed
- D. Suction q4h
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of bed. Elevating the head of the bed helps improve lung expansion and ventilation, making it easier for patients with impaired respiratory function to breathe. This position also helps prevent aspiration and reduces the risk of respiratory complications. Antibiotics (choice A) are not indicated unless specifically prescribed for an infection. Bedrest (choice B) can lead to deconditioning and worsen respiratory function. Suctioning (choice D) every 4 hours is not necessary unless there is excessive secretions present.
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The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
- A. Use commercial preparations to remove
- B. Wash and inspect the feet daily
- C. Walk barefoot at least once each daily
- D. Cut the toenails by rounding edges
Correct Answer: B
Rationale: The correct answer is B: Wash and inspect the feet daily. This is important for clients with diabetes mellitus to prevent complications like foot ulcers. Daily foot care helps detect any issues early. Choice A is incorrect as it is not recommended to use commercial preparations without medical advice. Choice C is incorrect as walking barefoot can increase the risk of injury and infection. Choice D is incorrect as cutting toenails by rounding edges can lead to ingrown toenails, which can be dangerous for clients with diabetes.
What is an example of a nurse modifying the care plan during the evaluation phase?
- A. Adding a new intervention to address an unmet goal.
- B. Performing routine monitoring of the client’s condition.
- C. Administering medication as prescribed by the physician.
- D. Completing discharge paperwork for the client.
Correct Answer: A
Rationale: The correct answer is A because modifying the care plan during the evaluation phase involves making changes based on the client's response to interventions. By adding a new intervention to address an unmet goal, the nurse demonstrates critical thinking and adaptability in response to the client's needs. This action shows that the nurse is actively assessing and revising the care plan to ensure it is effective in meeting the client's goals.
Choice B is incorrect because routine monitoring is part of the assessment and implementation phases, not specifically related to modifying the care plan during evaluation. Choice C is incorrect as administering medication is part of the implementation phase and does not necessarily involve modifying the care plan. Choice D is also incorrect as completing discharge paperwork is typically part of the discharge planning phase, not the evaluation phase where modifications to the care plan are made based on client outcomes.
A 45-year old female diabetic is displaying signs of irritability and irrational behavior during an office visit. The nurse observes visible tremors in the client’s hands. based on the client’s history and the nurse’s understanding of diabetes mellitus, the nurse interprets these findings to be signs of:
- A. hyperglycemia
- B. hyperglycemic hyperosmolar
- C. diabetic ketoacidosis (DKA) nonketosis (HHNK)
- D. hypoglycemia
Correct Answer: D
Rationale: The correct answer is D: hypoglycemia. In a diabetic patient, signs of irritability, irrational behavior, and visible tremors in the hands indicate low blood sugar levels, which is hypoglycemia. This is because the brain relies on glucose for energy, and when blood sugar levels drop too low, it can lead to neuroglycopenic symptoms such as confusion and tremors.
Explanation for why the other choices are incorrect:
A: hyperglycemia - High blood sugar levels typically present with symptoms such as frequent urination, increased thirst, and fatigue, not irritability and tremors.
B: hyperglycemic hyperosmolar - This condition is characterized by extremely high blood sugar levels and severe dehydration, leading to symptoms such as extreme thirst and confusion, not irritability and tremors.
C: diabetic ketoacidosis (DKA) nonketosis (HHNK) - These conditions are associated with high blood sugar levels and metabolic disturbances,
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C):
1. Safety first: Patient safety is the top priority in healthcare. Vital signs provide crucial information about the patient's condition.
2. Accountability: The nurse is responsible for ensuring accurate vital sign documentation. Asking the NAP to record vital signs before medication administration ensures accountability.
3. Communication: Clear communication between healthcare team members is essential to provide quality care. Asking the NAP to record vital signs promotes effective communication.
Summary of Incorrect Choices:
A (abnormal vital signs): Administering medications without knowing the patient's vital signs, especially if abnormal, can be dangerous and potentially harmful.
B (review upon return): Delaying vital sign assessment until later can lead to missed opportunities for timely intervention if the patient's condition changes.
D (omit vital signs): Neglecting vital signs based on assumption risks overlooking potential issues that could impact patient care and outcomes.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Asking the NAP to record the patient's vital signs before administering medications is the correct clinical decision. Vital signs are crucial indicators of a patient's health status and should be documented before any interventions. By having the NAP record the vital signs, the nurse ensures that the patient's condition is properly assessed and monitored. This action aligns with the standard of care and promotes patient safety.
Summary of Incorrect Choices:
A: Administering medications without knowing the patient's vital signs could be dangerous, especially if there are abnormalities that need attention.
B: Reviewing vital signs upon return delays necessary assessment and intervention, potentially compromising patient safety.
D: Omitting vital signs without assessment puts the patient at risk, as changes in vital signs can indicate underlying issues that need immediate attention.