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The nurse has created a plan of care to include interventions focused on reassuming self-care for a client who is in traction. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
- A. The client denies a need for assistance with care.
- B. The client allows the family to assist in the care.
- C. The client assists in self-care as much as possible.
- D. The client allows the nurse to complete the care on a daily basis.
Correct Answer: C
Rationale: A successful outcome for reassuming self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to perform the care.
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The nurse assesses a client after abdominal surgery who has a nasogastric (NG) tube in place that is connected to suction. Which observation by the nurse indicates most reliably that the tube is functioning properly?
- A. The suction gauge reads low intermittent suction.
- B. The client indicates that pain is a 3 on a scale of 1 to 10.
- C. The distal end of the NG tube is pinned to the client's gown.
- D. The client denies nausea and has 250 mL of fluid in the suction collection container.
Correct Answer: D
Rationale: An NG tube connected to suction is used postoperatively to decompress and rest the bowel. The gastrointestinal tract lacks peristaltic activity as a result of manipulation during surgery. The client should not experience symptoms of ileus (nausea and vomiting) if the tube is functioning properly. Although the nurse makes pertinent observations of the tube to ensure that it is secure and properly connected to suction, the client is assessed for the effect. A pain indicator of 3 is an expected finding in a postoperative client.
A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse provides instructions to the client regarding the care of the disorder while at home. Which statement by the client indicates the need for further instruction?
- A. I can use an ophthalmic analgesic ointment at night if I have eye discomfort.
- B. I do not need to be concerned about spreading this infection to others in my family.
- C. I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my eye.
- D. I should perform saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is present.
Correct Answer: B
Rationale: Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime because discomfort becomes more noticeable when the eyelids are closed. When purulent discharge is present, saline eye irrigations or applications of warm compresses to the eye may be necessary before instilling the medication.
The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
- A. The client verbalizes the need to avoid snacking between meals.
- B. The client discusses the relationship between mealtime and the blood glucose level.
- C. The client maintains a normal weight or gradually gains weight if it is below normal.
- D. The client demonstrates knowledge regarding the need to consume a diet that is high in fat and low in protein.
Correct Answer: C
Rationale: Graves' disease causes a state of chronic nutritional and caloric deficiency caused by the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite. Therefore, it is a nutritional goal that the client will not lose additional weight and he or she will gradually return to the ideal body weight, if necessary. To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks.
A woman in labor is receiving oxytocin by intravenous infusion. The nurse monitors the client, knowing that which finding indicates an adequate contraction pattern?
- A. One contraction per minute, with resultant cervical dilation
- B. Four contractions every 5 minutes, with resultant cervical dilation
- C. One contraction every 10 minutes, without resultant cervical dilation
- D. Three to 5 contractions in a 10-minute period, with resultant cervical dilation
Correct Answer: D
Rationale: The preferred oxytocin dosage is the minimal amount necessary to maintain an adequate contraction pattern characterized by 3 to 5 contractions in a 10-minute period, with resultant cervical dilation. If contractions are more frequent than every 2 minutes, contraction quality may be decreased.
The nurse reviews the nursing care plan of a hospitalized preschool child who is immobilized as a result of skeletal traction. The nurse notes concerns related to the child's development because of immobilization and hospitalization. Which evaluative statement indicates a positive outcome for the child?
- A. The fracture heals without complications.
- B. The caregivers verbalize safe and effective home care.
- C. The child maintains normal joint and muscle integrity.
- D. The child displays age-appropriate developmental behaviors.
Correct Answer: D
Rationale: Regression and inappropriate developmental behaviors may be displayed in response to immobilization and hospitalization. With individualized care planning, a positive outcome of age-appropriate behavior can be achieved. The remaining options are appropriate evaluative statements for an immobilized child, but they do not directly address the child's development.