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The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient’s face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: Rationale: A relaxed face during conversation typically does not indicate a hearing loss, as the patient is likely able to hear and understand. B, speaking loudly, is a common sign of hearing loss. C, turning towards the speaker, suggests an effort to hear better. D, being withdrawn, could indicate difficulty in communication due to hearing loss. Therefore, A is the correct answer as it does not align with typical signs of hearing loss.
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Which of the following measures will not help correct the patient’s condition
- A. Offer large amount of oral fluid intake to replace fluid lost
- B. Give enteral or parenteral fluid
- C. Frequent oral care
- D. Give small volumes of fluid at frequent interval
Correct Answer: C
Rationale: Step-by-step rationale:
1. Providing oral care does not directly address fluid balance or hydration status.
2. Oral care focuses on maintaining oral hygiene and preventing infections.
3. Choices A, B, and D all involve fluid intake to address dehydration.
4. Offering large amounts of fluid, enteral or parenteral fluids, and small volumes at frequent intervals all aim to correct the patient's condition by replenishing lost fluids.
Summary:
Choice C is incorrect because oral care does not directly address the patient's dehydration. Choices A, B, and D are better options as they focus on fluid replacement to correct the patient's condition.
The LPN is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, “I know I am not going to wake up after surgery.” Which of the following actions should the nurse take?
- A. Reassure patient everything will be all right
- B. Explain national surgery death rate
- C. Inform the registered nurse
- D. Ask family to comfort the patient
Correct Answer: C
Rationale: The correct answer is C: Inform the registered nurse. This is the best course of action as the LPN should escalate the situation to a higher level of care by involving the registered nurse who can further assess the patient's concerns and provide appropriate interventions.
A. Reassuring the patient may not address the underlying fear and may not be sufficient to alleviate their anxiety.
B. Providing statistics about surgery death rates may further escalate the patient's fears and anxiety, causing more harm than good.
D. Involving the family to comfort the patient may not address the patient's specific concerns and may not be within the family's scope of understanding or expertise to effectively address the situation.
Informing the registered nurse allows for a more comprehensive assessment and appropriate intervention to address the patient's fears and concerns in a holistic manner.
While bathing an 82 y.o. man hospitalized with pneumonia, a nurse notes an ulcerated area on his penis. What action should the nurse take first?
- A. Report the ulcer to the admitting care provider.
- B. Teach the man about STD prevention.
- C. Ask the man if he has a history of syphilis.
- D. Clean the ulcer; reporting is not necessary because an STD is unlikely in a man this age.
Correct Answer: A
Rationale: The correct action is to report the ulcer to the admitting care provider first. This is essential because the ulcer could be a sign of an underlying infection or condition that needs immediate attention, especially in a hospitalized patient with pneumonia. Reporting the ulcer ensures prompt evaluation and appropriate treatment. The other options are incorrect because teaching about STD prevention and asking about syphilis assume the cause of the ulcer is related to a sexually transmitted infection, which may not be the case in this scenario. Additionally, cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can lead to complications or delay in appropriate treatment.
Which action indicates the nurse is using a PICOT question to improve care for a patient?
- A. Practices nursing based on the evidence presented in court
- B. Implements interventions based on scientific research
- C. Uses standardized care plans for all patients. NursingStoreRN
- D. Plans care based on tradition
Correct Answer: B
Rationale: The correct answer is B because using a PICOT question involves formulating a research question to guide evidence-based practice. B indicates the nurse is implementing interventions based on scientific research, aligning with the PICOT framework (Patient, Intervention, Comparison, Outcome, Timeframe). This approach ensures that care decisions are supported by the best available evidence, leading to improved patient outcomes.
Choice A is incorrect because practicing nursing based on court evidence does not align with the PICOT framework. Choice C is incorrect as using standardized care plans for all patients may not consider individual patient needs and preferences as required in a PICOT question. Choice D is incorrect as planning care based on tradition does not involve integrating current research evidence as in the PICOT approach.
Which of the following examples of client data needs to be validated?
- A. A client has trouble reading an informed consent, but states he does not need glasses.
- B. An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
- C. A nurse examining a client with a respiratory infection documents fever and chills.
- D. A client in a nursing home states that she is unable to eat the food being served.
Correct Answer: A
Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight.
- Choice B is about interpreting physical signs, not client data validation.
- Choice C involves documenting objective findings, not validating client information.
- Choice D pertains to a client's complaint, not necessarily requiring validation.