Nokea
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
- A. chest pain related to cough secondary to pneumonia
- B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
- C. risk for altered family processes secondary to hospitalization
- D. self-esteem deficit situational
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.
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The physician has ordered a low-potassium diet for a client with renal failure. Which food should be limited due to its potassium content?
- A. Broccoli
- B. Bananas
- C. Lean beef
- D. White rice
Correct Answer: B
Rationale: Bananas, with ~400-450 mg potassium per fruit, must be limited on a low-potassium diet in renal failure, as impaired kidneys can't excrete excess, risking hyperkalemia broccoli's moderate, beef and rice's low potassium fit better. Nurses teach this, preventing cardiac issues, tailoring diets for renal safety.
The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning a morphine order for pancreatitis exemplifies the client advocate role, where nurses safeguard patient well-being. Morphine can worsen pancreatitis by causing sphincter of Oddi spasm, unlike safer options like meperidine. By challenging this, the nurse protects the client from harm, a duty rooted in ethical codes like the ANA's. Change agents modify behaviors, case managers coordinate, and collaborators work jointly, but advocacy uniquely prioritizes patient safety over compliance. In practice, this might involve consulting the doctor for an alternative, ensuring care aligns with the patient's best interest, a critical nursing responsibility.
Which of the following is an example of relaxation technique?
- A. Guided imagery
- B. Distraction
- C. TENS
- D. Acupuncture
Correct Answer: A
Rationale: Guided imagery (A) is a relaxation technique, calming via imagined scenes, per pain management categories. Distraction (B) diverts attention, TENS (C) uses electrical stimulation, acupuncture (D) needles none primarily relax. A reduces tension and stress, fitting relaxation's goal, making it the correct example.
An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
- A. Stiffness of the right ankle joint
- B. Soreness of the gums
- C. Short-term memory loss
- D. Decreased appetite
Correct Answer: A
Rationale: Joint stiffness signals early contractures or atrophy from immobility.
Which of the following nursing intervention is appropriate when an IV infusion infiltrates?
- A. Elevate the site
- B. Discontinue the infusion
- C. Attempt to flush the tube
- D. Apply warm, moist compress
Correct Answer: B
Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.