Nokea
Priority Decision: When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next?
- A. Note this information in the patient's record as hay fever and food allergies.
- B. Place an allergy alert wristband that identifies the specific allergies on the patient.
- C. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.
- D. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.
Correct Answer: C
Rationale: Understanding the nature and severity of allergies helps in planning appropriate perioperative care and avoiding potential allergens.
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What nursing measure assumes priority for Mr. Johnson with sudden diarrhea and high fever?
- A. Determine if he had been working on an air-conditioning unit of a high-rise building
- B. Place the patient in isolation
- C. Monitor respiratory status carefully and observe for signs of hypoxia
- D. Begin discharge teaching
Correct Answer: C
Rationale: The correct answer is C, to monitor respiratory status and observe for signs of hypoxia. This is because sudden diarrhea and high fever can indicate a potential infectious illness, which can lead to respiratory complications such as pneumonia. Monitoring respiratory status is crucial to detect any signs of respiratory distress or hypoxia early on.
A: Determining his work on an air-conditioning unit is not a priority at this time as it does not directly address his immediate health concerns.
B: Placing the patient in isolation may be necessary later depending on the diagnosis, but it is not the priority at this moment.
D: Beginning discharge teaching is not appropriate as the patient is currently experiencing acute symptoms that require immediate attention.
In summary, monitoring respiratory status is the priority to ensure early detection and intervention for any potential respiratory complications in a patient with sudden diarrhea and high fever.
When should discharge planning begin for a patient in a tertiary-care facility?
- A. On the day of admission
- B. After the acute crisis is resolved
- C. When the physician writes the discharge order
- D. When the patient demonstrates readiness to discuss posthospitalization needs
Correct Answer: A
Rationale: Rationale:
A: Discharge planning should begin on the day of admission to ensure a smooth transition. This early start allows for comprehensive assessment and coordination of post-discharge needs.
B: Waiting until after the acute crisis is resolved may lead to rushed planning and potential gaps in care.
C: Discharge planning should not solely rely on the physician's discharge order as it may not address all aspects of the patient's needs.
D: Patient readiness is important, but starting planning early ensures sufficient time for assessment and interventions.
What are the priority nursing diagnoses for a client in shock?
- A. Increased urine output
- B. Edema
- C. Hypertension
- D. Hypernatremia
Correct Answer: B
Rationale: Edema occurs due to excess fluid accumulation in the interstitial spaces, commonly seen in conditions like heart failure and kidney disease.
Instructions for a patient at risk for testicular cancer include
- A. Restrict potassium, phosphate, sodium, protein in diet.
- B. Self-catheterization of ileal reservoir.
- C. Testicular self-exam.
- D. Change in color of urine is to be expected.
Correct Answer: C
Rationale: Regular self-exams help detect testicular cancer early.
A client has undergone the Snellen eye chart and has 20/40 vision. Which of the following is true for this client?
- A. The client sees letters at 20 feet that others can read at 40 feet
- B. The client sees letters at 40 feet that others can read at 20 feet
- C. The client sees colors at 20 feet that others can see at 40 feet
- D. The client sees colors at 40 feet that others can see at 20 feet
Correct Answer: A
Rationale: 20/40 vision means the client can see at 20 feet what a person with normal vision can see at 40 feet.