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The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
- A. Space the administration every 4 hours.
- B. Use the drug for a short time only
- C. Take piroxicam with food or oral antacid
- D. Decrease the piroxicam dosage
Correct Answer: C
Rationale: The correct answer is C: Take piroxicam with food or oral antacid. This instruction helps to reduce GI irritation by providing a protective barrier for the stomach lining. Piroxicam is known to cause GI upset due to its effect on prostaglandin synthesis. Taking it with food or an antacid can help minimize this side effect.
Choice A (Space the administration every 4 hours) does not address the issue of GI irritation and is not a recommended strategy for preventing this side effect.
Choice B (Use the drug for a short time only) is not a direct intervention to prevent GI upset and does not provide guidance on how to manage the side effect when taking the medication.
Choice D (Decrease the piroxicam dosage) may not be necessary if the client can manage the side effects with the simple intervention of taking it with food or an antacid.
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A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
- A. Wash the area with soap and warm water
- B. Leave the skin alone until it is clear
- C. Apply a cream or lotion to the area
- D. Avoid applying creams or lotion to the area
Correct Answer: C
Rationale: The correct answer is C: Apply a cream or lotion to the area. This is because radio-dermatitis is a common side effect of radiation therapy, causing skin irritation and dryness. Applying a cream or lotion helps to moisturize the skin, reduce inflammation, and promote healing. Washing the area with soap can further irritate the skin. Leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions can worsen dryness and discomfort. Overall, applying a suitable cream or lotion is the most effective method to alleviate symptoms and support skin recovery in radio-dermatitis.
Wilma knew that James have an adequate respiratory condition if she notices that
- A. James’ respiratory rate is 18
- B. James’ Oxygen saturation is 91%
- C. There are frank blood suction from the tube
- D. There are moderate amount of tracheobronchial secretions
Correct Answer: A
Rationale: The correct answer is A because a normal respiratory rate for an adult is typically between 12-20 breaths per minute. A respiratory rate of 18 falls within this range, indicating adequate respiratory function.
Choice B is incorrect because an oxygen saturation of 91% is below the normal range of 95-100%, suggesting potential respiratory insufficiency.
Choice C is incorrect as frank blood suction from the tube indicates a serious issue such as bleeding, not adequate respiratory condition.
Choice D is also incorrect as the presence of a moderate amount of tracheobronchial secretions may indicate a respiratory infection or other respiratory issue, not necessarily adequate respiratory condition.
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
- A. Measure the client’s oral temperature.
- B. Ask a colleague for assistance.
- C. Give the client a clean gown and warm blankets.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: The correct answer is A: Measure the client’s oral temperature. This is the best follow-up because it directly assesses the client's body temperature, providing objective data to confirm the presence of fever. It is essential to gather accurate information to guide appropriate interventions. Asking a colleague for assistance (B) may not address the immediate need for temperature assessment. Giving the client a clean gown and warm blankets (C) may provide comfort but does not address the need for temperature measurement. Obtaining an order for blood cultures (D) is not the initial priority when the client is showing signs of fever; temperature measurement is the first step in assessing the client's condition.
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
- A. “Choose all the interventions and perform them in order of time needed for each one.”
- B. “Make sure you identify the scientific rationale for each intervention first.”
- C. “Decide on goals and outcomes you have chosen for the patients.”
- D. “Begin with the highest priority diagnoses, then select appropriate interventions.”
Correct Answer: D
Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions."
Rationale:
1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being.
2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery.
3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient.
4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes.
Summary:
A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs.
B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses.
C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. This type of diagnosis focuses on improving the client's well-being and maximizing their health potential. By adding Readiness for enhanced urinary elimination to the care plan, the nurse acknowledges the patient's willingness to learn self-catheterization, which aligns with health promotion. Other choices are incorrect because: A (Risk) implies potential harm, B (Problem focused) focuses on current issues, and D (Collaborative problem) involves multiple healthcare providers working together on a specific problem.