Nokea
One GOOD nursing intervention of the nurse for Almira would be to do which of the following?
- A. Advise her to eat her meals.
- B. Put her on absolute bed rest.
- C. Take the vital signs q 4 hours.
- D. Advise her to take care of Jay.
Correct Answer: A
Rationale: The correct nursing intervention for Almira would be to advise her to eat her meals. This is important in promoting her health and well-being, especially if she has been neglecting her own nutrition due to stress or caring for her son, Jay. Providing proper nutrition is a basic aspect of nursing care that supports the overall health and recovery of the patient. By encouraging Almira to prioritize her own nutrition, the nurse can help ensure that she has the physical strength and energy needed to take care of herself and her son effectively.
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A patient with a history of cirrhosis is at risk for developing hepatic encephalopathy. Which nursing intervention is most effective in preventing and managing hepatic encephalopathy?
- A. Administering lactulose as prescribed
- B. Restricting dietary protein intake
- C. Monitoring serum ammonia levels
- D. Encouraging increased fluid intake
Correct Answer: A
Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.
When determining the existence of malpractice, which factor is NOT considered?
- A. Injury
- B. Causation
- C. Duty
- D. Intent
Correct Answer: D
Rationale: When determining the existence of malpractice, intent is not considered as a factor. Malpractice typically involves unintentional actions or negligence rather than a deliberate intent to cause harm. The key factors that are usually considered in a malpractice case include duty (a legal obligation to provide a certain standard of care), causation (the link between the provider's actions and the patient's injury), and the existence of an injury resulting from the provider's actions or omissions. Intent does not play a direct role in malpractice cases, as they are focused on the standard of care provided by the healthcare professional and the harm caused as a result.
Which of the following nursing actions should the nurse TEACH the patient's care giver regarding tracheostomy care?
- A. Remove the tracheostomy tube if obstruction occurs
- B. Leave the tracheostomy ties in place until the physician change them
- C. Remove and clean the inner cannula daily
- D. Never put a covering over the tracheostomy stoma
Correct Answer: C
Rationale: Cleaning the inner cannula daily helps prevent the accumulation of secretions and debris, which can lead to blockages and infections. It is an essential aspect of tracheostomy care to maintain the patency of the airway and prevent complications. Caregivers should be taught how to safely remove, clean, and reinsert the inner cannula as part of routine tracheostomy care.
A patient presents with chest pain that occurs at rest and is exacerbated by deep breathing or changes in body position. The pain improves with leaning forward. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Pericarditis
- D. Myocarditis
Correct Answer: C
Rationale: Pericarditis is the inflammation of the pericardium, the sac surrounding the heart. Patients with pericarditis typically present with sharp chest pain that worsens with deep breathing, changes in body position, and coughing. The pain tends to improve when the patient leans forward. This characteristic symptom of pericarditis is known as "pleuritic" chest pain. In contrast, stable angina presents as predictable chest pain that occurs with exertion and is relieved by rest or medications. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion and is considered a medical emergency. Myocarditis involves inflammation of the heart muscle and may present with symptoms such as chest pain, but it does not typically have the characteristic of worsening with deep breathing or changes in body position.
A woman in active labor has been diagnosed with placenta previa. What is the priority nursing intervention?
- A. Prepare for immediate cesarean section.
- B. Administer intravenous oxytocin to augment labor.
- C. Insert a Foley catheter to monitor urine output.
- D. Implement bed rest and continuous fetal monitoring.
Correct Answer: A
Rationale: In the case of a woman in active labor with placenta previa, the priority nursing intervention is to prepare for an immediate cesarean section. Placenta previa is a condition in which the placenta covers part or all of the cervix, which can lead to severe bleeding during labor and delivery. The risk of hemorrhage is significant, making a cesarean section the safest option for both the mother and the baby in this situation. It is crucial to act promptly to prevent complications and ensure the well-being of both the mother and the baby. Administering intravenous oxytocin to augment labor or inserting a Foley catheter to monitor urine output would not address the immediate risk of hemorrhage associated with placenta previa. Implementing bed rest and continuous fetal monitoring may be part of the overall care plan but not the priority intervention in this urgent situation.