Nokea
Nurse Melanie is teaching an adult class about the different types of hepatitis. Which statement does not pertain to hepatitis A?
- A. “Is caused by an RNA virus of the enterovirus family.”
- B. “It spreads primarily by fecal-oral route, usually through the ingestion of infcetd food or liquids.”
- C. “It may not be spread from sexual contact.”
- D. “Type A hepatitis occurs worldwide, especially in areas with overcrowding and poor sanitation.”
Correct Answer: A
Rationale: The correct answer is A because hepatitis A is caused by a virus from the Picornaviridae family, not the enterovirus family. Hepatitis A spreads through contaminated food or water, not through sexual contact. It is true that hepatitis A occurs worldwide in areas with poor sanitation, but the virus is not from the enterovirus family. Choices B, C, and D are incorrect because they all pertain to hepatitis A characteristics.
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Total parenteral nutrition (TPN) is ordered for an adult client. Which nutrient is not likely to be in the solution?
- A. dextrose
- B. electrolytes
- C. trace minerals
- D. amino acids
Correct Answer: C
Rationale: The correct answer is C: trace minerals. TPN solutions typically include dextrose for energy, electrolytes for maintaining fluid balance, and amino acids for protein synthesis. Trace minerals are not typically included in TPN solutions as they are only required in small amounts and can be toxic in excess. Therefore, it is not likely to be in the solution. The other choices (A, B, D) are essential components of TPN solutions necessary for meeting the nutritional needs of the patient.
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.
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The correct answer is B. Placing the patient on the right side with support to the back, pillows for body alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled is most appropriate for a patient with right-sided paralysis following a stroke. This position helps prevent contractures by maintaining proper alignment and positioning of the limbs. Placing the washcloth to curl the fingers helps prevent hand contractures. Supporting the back and keeping the hips slightly flexed also helps prevent pressure ulcers and maintains proper body alignment.
Choice A is incorrect because tightly holding a rolled washcloth may cause discomfort and restrict blood flow.
Choice C is incorrect because placing the patient on the back with a pillow under the knees does not address the specific needs of a patient with right-sided paralysis.
Choice D is incorrect because lying on the back with trochanter rolls and a footboard does not address the specific needs of a patient with right-sided paralysis and may not prevent contractures effectively.
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
- A. Risk for increased cardiac output related to fluid volume excess
- B. Disturbed sensory perception related to bleeding into tissues
- C. Alteration in tissue perfusion related to bleeding and diminished blood flow
- D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C
Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues.
Explanation:
1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output.
2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception.
3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body.
In summary, the correct answer is C because DIC can lead to altered tissue perfusion
What is an example of a nurse modifying the care plan during the evaluation phase?
- A. Adding a new intervention to address an unmet goal.
- B. Performing routine monitoring of the client’s condition.
- C. Administering medication as prescribed by the physician.
- D. Completing discharge paperwork for the client.
Correct Answer: A
Rationale: The correct answer is A because modifying the care plan during the evaluation phase involves making changes based on the client's response to interventions. By adding a new intervention to address an unmet goal, the nurse demonstrates critical thinking and adaptability in response to the client's needs. This action shows that the nurse is actively assessing and revising the care plan to ensure it is effective in meeting the client's goals.
Choice B is incorrect because routine monitoring is part of the assessment and implementation phases, not specifically related to modifying the care plan during evaluation. Choice C is incorrect as administering medication is part of the implementation phase and does not necessarily involve modifying the care plan. Choice D is also incorrect as completing discharge paperwork is typically part of the discharge planning phase, not the evaluation phase where modifications to the care plan are made based on client outcomes.