Nokea
Match the following care planning tools to the description statement(s). There may be more than one statement per tool and some statements may be used more than once.
- A. Nursing Care Plan
- B. Concept Maps
- C. Clinical Pathway
- D. All
Correct Answer: A
Rationale: Nursing Care Plans direct teams, Concept Maps visualize relationships, and Clinical Pathways guide predictable cases.
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Which patient is at greatest risk for pancreatic cancer?
- A. An elderly black male with a history of smoking and alcohol use.
- B. A young,white obese female with no known health issues.
- C. A young black male with juvenile onset diabetes.
- D. An elderly white female with a history of pancreatitis.
Correct Answer: A
Rationale: Smoking and alcohol use are major risk factors for pancreatic cancer, making the elderly black male with these habits at highest risk.
During a call to the on-call physician about a client who had a hysterectomy 2 days ago & has unrelieved pain from prescribed narcotic medication, which statement is part of the SBAR format for communication?
- A. I suggest ordering a different pain medication.
- B. This client has allergies to morphine & codeine.
- C. Dr. Smith does not prefer nonsteroidal anti-inflammatory meds.
- D. The client had a vaginal hysterectomy 2 days ago.
Correct Answer: B
Rationale: The correct answer is B because it provides relevant information regarding the client's allergies to morphine and codeine, which is crucial for the physician to know when considering alternative pain medication options. This aligns with the "Background" component of the SBAR format, which includes pertinent patient history.
Choice A is incorrect because it jumps to a solution without providing necessary background information. Choice C is irrelevant to the current situation as it does not address the client's pain management issue. Choice D is also incorrect as it only provides historical information about the type of hysterectomy performed, which is not directly related to the client's current pain management concern.
A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding should you instruct the student to report immediately?
- A. Respiratory rate of 8 to 10 per minute
- B. Pain level decreased from 6/10 to 2/10
- C. Client requests room door be closed
- D. Heart rate 90-100 per minute
Correct Answer: A
Rationale: Oxycodone can depress respiration; a respiratory rate of 8-10 per minute is abnormally low and requires immediate attention to prevent respiratory failure.
Why are older adults more likely to develop hypovolemic shock?
- A. Low-activity lifestyle
- B. Altered cardiac function
- C. Decreased percentage of body water
- D. Decline in muscle strength and bone mass
Correct Answer: C
Rationale: Older adults have less total body water, making them more susceptible to fluid losses and hypovolemic shock.
What is one reason that might apply to a client’s rationale for using alternative therapy?
- A. Desire to become more active in decision-making and self-care.
- B. Chronic incurable back condition.
- C. Difficulty meeting the rising costs of healthcare.
- D. Client does not share traditional American health beliefs and practices.
Correct Answer: A
Rationale: Clients often seek alternative therapies to take a more active role in their healthcare decisions and self-management.