Nokea
Morphine is given in acute pulmonary edema to redistribute the pulmonary circulation to the periphery by decreasing:
- A. Periphery resistance
- B. Pulmonary capillary pressure
- C. Transudation of fluid
- D. All of the above CARING FOR CLIENTS WITH HEART FAILURE
Correct Answer: D
Rationale: The correct answer is D because morphine helps in acute pulmonary edema by decreasing peripheral resistance, pulmonary capillary pressure, and transudation of fluid. Morphine causes vasodilation, reducing peripheral resistance, which helps redistribute blood flow to the periphery. It also reduces pulmonary capillary pressure by decreasing preload and afterload, leading to decreased fluid transudation into the alveoli. Choices A, B, and C individually do not cover all the effects of morphine in acute pulmonary edema, making them incorrect.
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A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (azidothymidine, AZT [Retrovir]). To check for adverse drug effects, the nurse should monitor the results of laboratory test?
- A. RBC count
- B. Serum calcium
- C. Fasting blood glucose
- D. Platelet count
Correct Answer: D
Rationale: The correct answer is D: Platelet count. Zidovudine (AZT) is known to cause bone marrow suppression, leading to decreased platelet production. Monitoring platelet count is crucial to detect early signs of thrombocytopenia, a common adverse effect of AZT.
Rationale:
A) RBC count: AZT can cause anemia, not specifically affecting the RBC count.
B) Serum calcium: AZT does not typically affect calcium levels.
C) Fasting blood glucose: AZT can cause hyperglycemia, but fasting blood glucose monitoring is not as critical as monitoring platelet count for AZT therapy.
Mrs. Diwa has been diagnosed with systemic lupus erythematosus, the nurse upon assessment can expect to find which of the following?
- A. dysphagia
- B. dryness or itching of genitalia
- C. decreased visual acuity or blindness
- D. abnormal lung sounds
Correct Answer: D
Rationale: The correct answer is D because systemic lupus erythematosus can lead to inflammation in the lungs, causing abnormal lung sounds. Dysphagia (choice A) is not typically associated with lupus. Dryness or itching of genitalia (choice B) is more characteristic of conditions like yeast infections or dermatitis. Decreased visual acuity or blindness (choice C) is not a common manifestation of lupus. Abnormal lung sounds (choice D) are commonly seen in lupus patients due to inflammation and possible lung involvement.
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: C
Rationale: The correct answer is C: Maintaining the integrity of the urinary system. This is crucial in preoperative preparation for a client with malignant tumors to prevent complications such as urinary obstruction or infection. Assessing symptoms of peritonitis (B) is important but not as critical as ensuring urinary system integrity. Insertion of an ostomy pouch (A) and nasogastric tube diversion procedure (D) may be necessary interventions for some cases, but they are not as essential as ensuring the urinary system's integrity to prevent serious complications.
What common problem is related to outcome identification and planning?
- A. Failing to involve the client in the planning process
- B. Collecting sufficient data to establish a database
- C. Stating specific and measurable outcomes based on nursing diagnoses
- D. Writing nursing orders that are clear and resolve the problem
Correct Answer: A
Rationale: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting.
Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be observed or measured by others. In this case, choice C is correct because the patient describing excitement about discharge is personal and based on the patient's feelings or perceptions. This is subjective data because it is based on the patient's own experiences and emotions. Choices A and B are incorrect because patient's temperature and wound appearance are objective data that can be measured or observed by the nurse. Choice D is also incorrect as patient pacing the floor is an observable behavior, making it objective data. Therefore, choice C is the correct answer as it represents subjective data in the context of the assessment.