Nokea
The most likely cause of her chief complaint this morning is
- A. A decrease in postoperative stress causing poiyuria
- B. The onset of diabetes mellitus, an unusual complication
- C. An expected result of the removal of the pituitary gland
- D. A frequent complication of the hypophysectomy
Correct Answer: D
Rationale: The correct answer is D because polyuria is a common complication following hypophysectomy (removal of the pituitary gland). This procedure can disrupt the regulation of antidiuretic hormone (ADH), leading to excessive urination. Choice A is incorrect as decreased stress would not cause polyuria. Choice B is unlikely as the onset of diabetes mellitus is not a typical immediate postoperative complication. Choice C is incorrect as removal of the pituitary gland would disrupt hormone regulation, possibly leading to polyuria, rather than being an expected result.
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Which of the following symptoms most likely indicates that an infusion is infiltrated?
- A. Redness at the site
- B. Pain at the site
- C. Puffiness at the site
- D. Exudate at the site
Correct Answer: C
Rationale: The correct answer is C: Puffiness at the site. This indicates infiltration of the infusion, where the medication or fluid leaks into the surrounding tissue instead of entering the bloodstream. Puffiness is a sign of fluid accumulation due to the infiltration. Redness at the site (A) may indicate infection, pain (B) can be due to various reasons, and exudate (D) may suggest infection or irritation, but they are not specific to infiltration. Infiltration assessment involves checking for swelling, coolness, and blanching around the infusion site.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Asking the NAP to record the patient's vital signs before administering medications is the correct clinical decision. Vital signs are crucial indicators of a patient's health status and should be documented before any interventions. By having the NAP record the vital signs, the nurse ensures that the patient's condition is properly assessed and monitored. This action aligns with the standard of care and promotes patient safety.
Summary of Incorrect Choices:
A: Administering medications without knowing the patient's vital signs could be dangerous, especially if there are abnormalities that need attention.
B: Reviewing vital signs upon return delays necessary assessment and intervention, potentially compromising patient safety.
D: Omitting vital signs without assessment puts the patient at risk, as changes in vital signs can indicate underlying issues that need immediate attention.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: The correct answer is C because it is essential for the nurse to ensure accurate and up-to-date vital signs before administering medications. By asking the NAP to record the patient's vital signs, the nurse can make informed decisions about the patient's condition and prevent any potential complications.
Choice A is incorrect because administering medications without knowing the patient's vital signs, particularly if they are abnormal, can be dangerous. Choice B is not the best course of action as it delays the crucial step of obtaining the vital signs. Choice D is incorrect as omitting vital signs without assessment could compromise patient safety. Therefore, choice C is the most appropriate response to ensure patient well-being and medication safety.
A patient’s chest x-ray examination indicates fluid in both lung bases. Which of the ff. signs or symptoms present during the nurse’s assessment most reflects these x-ray examination findings?
- A. Fatigue
- B. Peripheral edema
- C. Bilateral crackles
- D. Jugular vein distention
Correct Answer: C
Rationale: The correct answer is C, bilateral crackles. Fluid in both lung bases on x-ray indicates pulmonary edema, causing crackles on auscultation. Fatigue (A) is a nonspecific symptom. Peripheral edema (B) is a sign of fluid retention in the extremities, not lungs. Jugular vein distention (D) indicates increased central venous pressure, which is not specific to lung fluid.
Nurse Melanie is teaching an adult class about the different types of hepatitis. Which statement does not pertain to hepatitis A?
- A. “Is caused by an RNA virus of the enterovirus family.”
- B. “It spreads primarily by fecal-oral route, usually through the ingestion of infcetd food or liquids.”
- C. “It may not be spread from sexual contact.”
- D. “Type A hepatitis occurs worldwide, especially in areas with overcrowding and poor sanitation.”
Correct Answer: A
Rationale: The correct answer is A because hepatitis A is caused by a virus from the Picornaviridae family, not the enterovirus family. Hepatitis A spreads through contaminated food or water, not through sexual contact. It is true that hepatitis A occurs worldwide in areas with poor sanitation, but the virus is not from the enterovirus family. Choices B, C, and D are incorrect because they all pertain to hepatitis A characteristics.