Nokea
Marichu is admitted to the hospital because of hepatic failure and was prescribed with lactulose (Duphalac). The primary action of this drug is:
- A. prevent constipation
- B. decrease resident intestinal flora
- C. increase intestinal peristalsis
- D. prevent portal hypertension
Correct Answer: B
Rationale: The correct answer is B: decrease resident intestinal flora. Lactulose is a synthetic sugar that is not absorbed in the intestine and is used to decrease ammonia levels in patients with hepatic encephalopathy by promoting the growth of beneficial gut bacteria that help metabolize ammonia. This action helps reduce the toxic effects of ammonia on the brain.
A: prevent constipation - Lactulose may help with constipation, but its primary action in this scenario is to decrease resident intestinal flora.
C: increase intestinal peristalsis - Lactulose does not directly increase peristalsis.
D: prevent portal hypertension - Lactulose does not have a direct effect on preventing portal hypertension.
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The following are warning signs of cancer. Which one is not?
- A. Change In bladder and bowel habits
- B. Weight gain
- C. Indigestion or difficulty in swallowing
- D. Nagging cough or hoarseness
Correct Answer: B
Rationale: The correct answer is B, weight gain, as it is not typically considered a warning sign of cancer. Changes in bladder and bowel habits (A), indigestion or difficulty in swallowing (C), and a nagging cough or hoarseness (D) are commonly associated with various types of cancer. Weight gain is more commonly linked to factors such as diet, exercise, and hormonal imbalances rather than cancer. It is important to be vigilant about the other warning signs and seek medical attention if any of those symptoms persist.
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:
1. Safety: Recording vital signs is crucial for patient safety.
2. Accountability: The nurse is ultimately responsible for ensuring vital signs are documented accurately.
3. Communication: It is essential for the nurse to communicate with the NAP to address the missed vital signs.
4. Corrective Action: Asking the NAP to record vital signs before administering medications ensures proper monitoring.
5. Patient-Centered Care: Prioritizing patient well-being by ensuring vital signs are up-to-date.
Summary:
A: Incorrect. Administering medications without vital sign assessment is unsafe.
B: Incorrect. Reviewing vital signs upon return does not address the immediate need for accurate documentation.
D: Incorrect. Omitting vital signs compromises patient safety and violates standard nursing practice.
What is the primary purpose of validation as a part of assessment?
- A. To identify data to be validated
- B. To establish an effective nurse–client communication
- C. To maintain effective relationships with coworkers
- D. To plan appropriate nursing care
Correct Answer: D
Rationale: The primary purpose of validation in assessment is to ensure that the data collected is accurate and reliable to plan appropriate nursing care. Validation helps confirm the accuracy of data, identify inconsistencies, and ensure that the information gathered is trustworthy. By verifying the data, nurses can make informed decisions and tailor individualized care plans to meet the patient's needs effectively. Choices A, B, and C are incorrect because they do not directly relate to the purpose of validation in assessment. Choice A focuses on the identification of data, not the purpose of validation. Choice B and C pertain to communication and relationships, which are important but not the primary purpose of validation in the assessment process.
Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
- A. Hyperventilating James with 100% oxygen before and after suctioning
- B. Instilling 3 to 5 ml normal saline to loosen up secretion
- C. Applying suction during catheter withdrawal
- D. Suction the client every hour
Correct Answer: A
Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows:
1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity.
2. Oxygen toxicity can result in lung damage and other complications.
3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations.
Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.
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.