Nokea
Pulmonary edema is characterized by:
- A. Elevated left ventricular and-diastolic
- B. Increased hydrostatic pressure
- C. All of the above alterations
- D. A rise in pulmonary venous pressure
Correct Answer: C
Rationale: Rationale:
1. Pulmonary edema is caused by increased hydrostatic pressure in the pulmonary circulation.
2. Elevated left ventricular end-diastolic pressure signifies heart failure, a common cause of pulmonary edema.
3. A rise in pulmonary venous pressure is a consequence of increased hydrostatic pressure.
Therefore, all three alterations (A, B, D) are characteristic of pulmonary edema. Option C is correct. Choices A, B, and D are incorrect because they are all individually associated with pulmonary edema and collectively represent the condition.
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What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. Problem statement
- B. Defining characteristics
- C. Etiology of the problem
- D. Outcomes criteria
Correct Answer: C
Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem.
Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.
Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
- A. Ease the patient to the floor
- B. Insert a padded tongue depressor between his jaws
- C. Lift the patient and put him on the bed
- D. Restraint patient’s body movement
Correct Answer: A
Rationale: The correct answer is A: Ease the patient to the floor. This is the first step because it helps prevent injury during a seizure. Lowering the patient to the floor prevents falls and protects the patient's head. Choices B, C, and D are incorrect. Choice B can cause injury or obstruct the airway, choice C involves unnecessary movement, and choice D can lead to further harm or injury. It is crucial to prioritize safety and prevent harm during a seizure episode.
What is the focus of a diagnostic statement for a collaborative problem?
- A. The client problem
- B. The potential complication
- C. The nursing diagnosis
- D. The medical diagnosis
Correct Answer: B
Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying any potential complications that may arise due to the client's condition or treatment. This allows nurses and other healthcare professionals to anticipate and address these complications proactively.
A: The client problem - While important, the client problem is usually addressed in the nursing diagnosis rather than the diagnostic statement for a collaborative problem.
C: The nursing diagnosis - The nursing diagnosis focuses on the actual or potential health problems that the client is experiencing, which is different from the focus of a diagnostic statement for a collaborative problem.
D: The medical diagnosis - The medical diagnosis is the identification of a disease or condition by a healthcare provider, which is not the focus when identifying potential complications in a collaborative problem.
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
- A. Consider the client’s urine, feces, and vomitus to be highly radioactive
- B. Consider the client to be radioactive for 10 days after implant removal
- C. Allow soiled linens to remain in the room until after the client is discharged
- D. Maintain the client on complete bed rest with bathroom privileges only
Correct Answer: A
Rationale: The correct answer is A because bodily fluids and excretions (urine, feces, vomitus) can become contaminated with radiation from the implant. Therefore, they should be considered highly radioactive and handled appropriately.
Choice B is incorrect because the client may remain radioactive for a longer period than 10 days post-implant removal.
Choice C is incorrect because soiled linens should be handled according to radiation safety protocols and removed promptly.
Choice D is incorrect because bed rest is not necessary unless specifically indicated by the healthcare provider; the client should be encouraged to move around as tolerated to prevent complications.
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
- A. Cough as the cuff is being deflated
- B. Hold the breath as the cuff is being re-inflated
- C. Take a deep breath as the nurse deflates the
- D. Exhale deeply as the nurse re-inflates the cuff cuff
Correct Answer: D
Rationale: The correct answer is D: Exhale deeply as the nurse re-inflates the cuff.
Rationale:
1. When the cuff of the tracheostomy tube is deflated, the client should be instructed to exhale deeply to prevent aspiration of secretions.
2. Exhaling helps to clear the airway by pushing secretions out of the trachea, reducing the risk of aspiration.
3. Inhaling or holding the breath while the cuff is being re-inflated can increase the risk of inhaling secretions.
4. Coughing as the cuff is being deflated (choice A) may not be as effective in clearing secretions as exhaling deeply.
5. Taking a deep breath as the nurse deflates the cuff (choice C) may not be as effective as exhaling deeply in preventing aspiration.
In summary, choice D is the correct answer because exhaling deeply helps clear secretions and reduce the risk of aspiration, while the other choices may