Nokea
The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis?
- A. The client assists as much as possible in his care, demonstrating increased participation over time.
- B. The client allows the nurse to complete his care in an efficient manner without interfering.
- C. The client allows his wife to assume total responsibility for his care.
- D. The client allows his wife to complete his care to promote feelings of usefulness.
Correct Answer: A
Rationale: Increased participation in self-care indicates progress toward independence despite traction limitations.
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Which of the following indicates that the client with diabetes insipidus understands how to manage care?
- A. The client will maintain normal fluid and electrolyte balance.
- B. The client will select American Diabetes Association diet correctly.
- C. The client will state dietary restrictions.
- D. The client will exhibit serum glucose level within normal range.
Correct Answer: A
Rationale: Effective management of diabetes insipidus involves maintaining fluid and electrolyte balance through medication and adequate hydration.
A client with vasospastic disorder (Raynaud's phenomenon) is scheduled for sympathectomy. This surgery is performed:
- A. In the early stages of the disease to prevent further circulatory disturbances
- B. When the disease is controlled by medication
- C. When the client is unable to control stress-related vasospasm
- D. When all other treatment alternatives have failed
Correct Answer: D
Rationale: Sympathectomy, which severs sympathetic nerves to reduce vasospasm, is a last-resort treatment for Raynaud's when all other options (medications, lifestyle changes) fail. It is not performed early, when controlled, or solely for stress-related vasospasm.
Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
- A. Reassuring the client that pain will be relieved.
- B. Documenting the client's response to pain medication on a routine basis.
- C. Instructing the client to continue pressing the system's button whenever pain occurs.
- D. Titrating the client's pain medication until the client is free from pain.
Correct Answer: B
Rationale: Documenting the client's response to PCA is a key nursing responsibility to monitor efficacy and safety. Reassuring complete relief, instructing to press repeatedly, or titrating to pain-free status may be unrealistic or unsafe.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
- A. Change dressing per institutional policy.
- B. Culture drainage at insertion site.
- C. Notify physician.
- D. Position rolled towel under client's back, parallel to the spine.
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize
The nurse has reported to the hospital to work the evening shift on a respiratory unit. The nurse's assignment consists of four clients. Prioritize in order from highest to lowest priority how the nurse would assess the clients after receiving report.
- A. An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness of breath.
- B. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain.
- C. A 35-year-old client with suspected tuberculosis who is complaining of a cough.
- D. A 56-year-old client with emphysema who has a scheduled dose of a bronchodilator due to be administered, with no report of acute respiratory distress.
Correct Answer: A,B,C,D
Rationale: The client with pneumonia, fever, and shortness of breath is at highest risk for respiratory compromise (A). The postoperative client with pain (B) is next due to pain's impact on breathing. The client with suspected tuberculosis and cough (C) is lower priority but needs isolation precautions. The client with emphysema awaiting a scheduled bronchodilator (D) is stable.