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Ms. C is at risk for refeeding syndrome that is caused by rapid feeding. What should be the priority action of the health care team to prevent complications associated with this syndrome?
- A. Assess for signs of pallor of the extremities and sluggish capillary refill
- B. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention
- C. Observe for signs of secret purging and ingestion of water to increase weight
- D. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention
Correct Answer: B
Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.
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A patient expresses concerns about the potential side effects of a prescribed medication. What is the nurse's best approach to address these concerns?
- A. Dismiss the patient's concerns and reassure them that side effects are unlikely.
- B. Provide the patient with accurate information about potential side effects and management strategies.
- C. Ignore the patient's concerns and focus solely on administering the medication.
- D. Tell the patient that side effects are common and unavoidable.
Correct Answer: B
Rationale: The nurse's best approach to address a patient's concerns about the potential side effects of a prescribed medication is to provide the patient with accurate information about potential side effects and management strategies. It is important for the nurse to acknowledge the patient's concerns, listen attentively, and offer clear explanations to help alleviate any fears or uncertainties. Providing accurate information can empower the patient to make informed decisions about their healthcare and feel more confident in taking the prescribed medication. Dismissing or ignoring the patient's concerns can lead to mistrust and non-adherence to the treatment plan. It is essential for the nurse to prioritize open communication and patient education to ensure the patient's well-being and compliance with the prescribed medication regimen.
Which of the following statements indicates that the client needs further teaching?
- A. "I will have to avoid drinking nonalcoholic beer."
- B. "I will be able to eat cottage cheese without worrying."
- C. "I can eat green beans on this diet."
- D. I'm so glad I can have pizza as long as I don't order pepperoni."
Correct Answer: A
Rationale: The statement "I will have to avoid drinking nonalcoholic beer" indicates a potential misunderstanding as nonalcoholic beer is generally permitted on most diets. The client may need further teaching to clarify this misconception. The other statements indicate a good understanding of the dietary guidelines and do not raise concerns about misunderstanding.
The presence of any of these risk factors means that ______.
- A. Risk modification will have no effect on disease prevention
- B. The chances of getting the disease are increased
- C. A person with risk factors can get the disease
- D. The disease is guaranteed not to get disease
Correct Answer: B
Rationale: The presence of risk factors indicates an increased likelihood or susceptibility to developing a particular disease. While risk modification and healthy lifestyle choices can help reduce the risk, having these risk factors still increases the overall chances of getting the disease compared to individuals without the same risk factors. It is essential for individuals with risk factors to be proactive in managing their health to mitigate the increased risk.
Which of the following substances has abnormal values EARLY in the course of multiple myeloma (MM)?
- A. Red blood cells
- B. White blood cells
- C. Immunoglobulins
- D. Platelets
Correct Answer: C
Rationale: In the early stages of multiple myeloma (MM), abnormal values are often seen in the levels of immunoglobulins. This is due to the abnormal proliferation of plasma cells in the bone marrow, leading to overproduction of monoclonal immunoglobulins (M proteins). These abnormal immunoglobulins can be detected in blood tests and are a key diagnostic feature of MM. Changes in red blood cells, white blood cells, and platelets are not typically early indicators of multiple myeloma.
A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of:
- A. malpractice
- B. Negligence
- C. Harm to the patient
- D. Failure to follow the nurse practice act
Correct Answer: B
Rationale: Negligence refers to the failure to perform a duty of care that a reasonable person would have exercised in the same situation, resulting in harm or injury to another person. In this scenario, the nurse failed to perform an ordered irrigation of a feeding tube, which is a standard nursing duty. This failure to act according to the orders resulted in harm to the patient, indicating negligence on the part of the nurse. Malpractice is a specific type of negligence that occurs when a professional fails to provide the standard level of care, so in this case, it falls under the broader category of negligence. Harm to the patient is the consequence of the nurse's negligence, and failure to follow the nurse practice act may be a contributing factor to the negligence, but the primary issue is the failure to provide proper care - which is negligence.