Nokea
Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:
- A. strict isolation techniques and policies
- B. a semi-private room
- C. liberal, unrestricted visiting
- D. equipment shared between Mr. Boy and the other burn patients in the unit
Correct Answer: B
Rationale: The correct answer is B: a semi-private room. For a burn patient like Mr. Boy, a semi-private room is preferred to provide a more controlled environment for infection prevention, wound care, and privacy. Strict isolation (A) is not necessary as his burns are not infectious. Liberal visiting (C) can increase the risk of infection and compromise his recovery. Sharing equipment (D) can lead to cross-contamination and is not recommended for burn patients. In summary, a semi-private room balances infection control and patient comfort for burn patients.
You may also like to solve these questions
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
- A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
- B. Low levels of urine constituents normally excreted in the urine
- C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
- D. Electrolyte imbalance that could affect the blood’s ability to coagulate properly
Correct Answer: C
Rationale: Rationale for Correct Answer (C): A complete blood count (CBC) is used to identify abnormalities in red blood cells, white blood cells, and platelets. Hematocrit (HCT) and hemoglobin (Hb) levels are part of a CBC and indicate the oxygen-carrying capacity of the blood. Abnormally low HCT and Hb levels can signify conditions like anemia, which can impact a client's ability to undergo surgery due to potential complications related to oxygen delivery.
Summary of Incorrect Choices:
A: Potential hepatic dysfunction is not directly related to a CBC, and BUN/creatinine levels are markers for kidney function, not liver function.
B: Low levels of urine constituents are not assessed in a CBC, which focuses on blood components.
D: Electrolyte imbalance is not specifically tested in a CBC; it is usually evaluated through separate blood tests. Coagulation factors are not directly measured in a CBC.
What are the signs of organ rejection a nurse should closely monitor for when caring for a client after heart transplantation? Choose all that apply
- A. Low white blood cell count
- B. Dyspnea
- C. ECG changes
- D. Fever
Correct Answer: B
Rationale: The correct answer is B: Dyspnea. Dyspnea is a common sign of organ rejection after heart transplantation, indicating possible heart failure. Low white blood cell count (A) is not typically a direct sign of organ rejection. ECG changes (C) may occur but are not specific to organ rejection. Fever (D) is a non-specific symptom and can be caused by various factors. Dyspnea is a key indicator that the transplanted heart is not functioning properly and should be closely monitored.
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
- A. Where is the pain located?
- B. What causes the pain?
- C. Does it come and go?
- D. What does the pain feel like?
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis.
Explanation of other choices:
B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect.
C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location.
D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
- A. Anxiety related to barium enema
- B. Impaired gas exchange related to asthma
- C. Impaired physical mobility related to incisional pain
- D. Nausea related to adverse effect of cancer medication
Correct Answer: A
Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs.
Summary:
B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition.
C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself.
D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. In the first phase of the nursing process (assessment), the nurse collects data to form a comprehensive database about the patient's health status. This step is crucial as it provides the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining whether outcomes have been achieved (D) is in the fourth phase (evaluation). Completing a comprehensive database in the first phase ensures a thorough understanding of the patient's needs before proceeding to the next steps in the nursing process.