Nokea
Nursing intervention during the lumbar puncture procedure includes:
- A. Monitoring Mrs. GC’s color, pulse and respiration
- B. Labeling all laboratory specimens in numerical order
- C. Positioning Mrs. GC on her side with knees drawn up to her chest
- D. All of the above
Correct Answer: D
Rationale: Step 1: Monitoring Mrs. GC's color, pulse, and respiration is important to assess for any signs of distress during the procedure.
Step 2: Labeling all laboratory specimens in numerical order ensures accurate identification and prevents errors in specimen handling.
Step 3: Positioning Mrs. GC on her side with knees drawn up to her chest helps maintain proper spinal alignment and reduces the risk of complications.
Summary: Option D is correct because all the interventions mentioned are crucial for ensuring patient safety and procedural success. Options A, B, and C are incorrect individually as they each address only one aspect of the procedure, whereas the correct answer encompasses all necessary interventions.
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The nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
- A. Duodenal ulcer
- B. Weight gain
- C. Hemorrhoids
- D. Polyps
Correct Answer: D
Rationale: The correct answer is D: Polyps. Polyps in the colon are precancerous growths that can develop into colorectal cancer over time. Identifying polyps during a medical history interview can raise suspicion for colorectal cancer due to their potential to progress into malignancy. Duodenal ulcer (A) is not directly related to colorectal cancer. Weight gain (B) is a non-specific symptom and does not specifically indicate colorectal cancer. Hemorrhoids (C) are common and usually benign, not directly linked to colorectal cancer.
A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?
- A. “An evaluation helps you determine whether all nursing interventions were completed.”
- B. “During evaluation, you determine when to downsize staffing on nursing units.”
- C. “Nurses use evaluation to determine the effectiveness of nursing care.”
- D. “Evaluation eliminates unnecessary paperwork and care planning.”
Correct Answer: C
Rationale: The correct answer is C: “Nurses use evaluation to determine the effectiveness of nursing care.” Evaluation in nursing is essential to assess the outcomes of nursing interventions and determine the effectiveness of the care provided. It helps in identifying areas for improvement, making informed decisions, and ensuring quality patient care.
Choice A is incorrect because evaluation is not solely about checking completion of tasks but rather assessing the impact of those interventions on patient outcomes. Choice B is incorrect as evaluation is not related to staffing decisions but focuses on assessing the quality of care delivery. Choice D is incorrect as evaluation is not about eliminating paperwork but rather about improving care outcomes.
The patient develops a low-grade fever 18 hours post-operatively and has diminished breath sounds. Which of the following actions is most appropriate for the nurse to take to prevent complications? i.Administer antibiotics iv.Decrease fluid intake ii.Encourage coughing and deepbreathing v.Ambulate patient as ordered iii.Administer acetaminophen (Tylenol)
- A. 2and 5
- B. All of the above
- C. 1, 3 and 4
- D. All except 2
Correct Answer: A
Rationale: The correct answer is A: 2 and 5. Diminished breath sounds indicate possible atelectasis or pneumonia post-operatively, making coughing and deep breathing (2) and ambulation (5) crucial to prevent complications. Decreasing fluid intake (iv) can lead to dehydration, worsening the situation. Administering antibiotics (i) without further assessment may not be necessary at this point. Acetaminophen (iii) can help with fever but does not address the underlying respiratory issue.
A patient understands the common causes of urinary tract infection if he or she states the following, EXCEPT:
- A. “UTI can be caused by holding the urge to urinate.”
- B. “Insertion of instruments and catheter to the urinary tract can introduce bacteria that can cause infection.”
- C. “I usually drink lots of water at night and it might have caused my UTI.”
- D. “UTI can be caused by unhygienic cleaning after defecation.”
Correct Answer: C
Rationale: Rationale: Choice C is the correct answer because drinking lots of water at night actually helps prevent UTIs by flushing out bacteria from the urinary tract. Holding the urge to urinate (Choice A) can increase the risk of UTIs as bacteria can multiply in stagnant urine. Insertion of instruments and catheters (Choice B) can introduce bacteria, leading to infection. Unhygienic cleaning after defecation (Choice D) can also introduce bacteria to the urinary tract, causing UTIs. Therefore, Choice C is the exception as it does not contribute to the common causes of UTIs.
Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
- A. A sudden raise in BP may occur during the first 1-3 hours after the initial dose
- B. A sudden drop in BP may occur during the first 1-3 hours after the initial dose
- C. A sudden drop in body temperature may occur during the first 1-3hours after the initial dose
- D. A sudden rise in pulse rate may occur during the first 1-3 hours after the initial dosage CARING WITH CLIENTS WITH CEREBROVASCULAR DISORDER
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications.
Incorrect choices:
A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors.
C: Angiotensin converting enzyme inhibitors do not affect body temperature.
D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate.
In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.