Nokea
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.
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A client asks the nurse what PSA is. The nurse should reply that is stands for:
- A. Prostate-specific antigen, which is used to screen for prostate cancer
- B. Protein serum antigen, which is used to determine protein levels
- C. Pneumococcal strep antigen, which is bacteria that causes pneumonia
- D. Papanicolua-specific antigen, which is used to screen for cervical cancer
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Prostate-specific antigen (PSA) is a protein produced by the prostate gland. It is primarily used to screen for prostate cancer by measuring the levels of PSA in the blood. PSA levels can help detect prostate cancer early. Therefore, choice A is the correct answer as it accurately describes PSA and its primary use.
Summary of Incorrect Choices:
B: Protein serum antigen is not a commonly known term in healthcare. There is no specific antigen called "protein serum antigen" used to determine protein levels.
C: Pneumococcal strep antigen is a bacterial antigen that causes pneumonia, not related to PSA used in prostate cancer screening.
D: Papanicolua-specific antigen is not a recognized term. The Papanicolaou test (Pap smear) is used for cervical cancer screening, not a specific antigen like PSA.
Which assessment finding would prompt the Rn to suspect compartment syndrome in a patient with a long leg cast?
- A. weak movement of the patient’s toes
- B. decreased pedal pulses
- C. severe, unrelieved pain
- D. presence of foot pallor
Correct Answer: C
Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.
The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
- A. 24 hours
- B. 7 to 14 days
- C. 2 to 4 days
- D. 21 to 28 days
Correct Answer: B
Rationale: The correct answer is B: 7 to 14 days. Marrow suppression from floxuridine typically occurs 1-2 weeks after administration due to its effects on rapidly dividing cells in the bone marrow. This is known as the nadir period. Choices A, C, and D are incorrect because 24 hours is too soon for noticeable effects, 2 to 4 days is too short for the nadir period, and 21 to 28 days is too long for the onset of marrow suppression. The correct choice aligns with the expected timeframe for floxuridine's impact on bone marrow function.
To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium:
- A. In patients who are unconscious
- B. In patients who show neurologic
- C. To prevent fluid overload symptoms
- D. To prevent dehydration
Correct Answer: C
Rationale: Step 1: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood.
Step 2: Restricting fluid intake helps prevent further dilution of sodium in the blood, aiding in correcting hyponatremia.
Step 3: Administering sodium can lead to rapid correction, risking osmotic demyelination syndrome.
Step 4: Choice C is correct as it aligns with the goal of managing hyponatremia by preventing fluid overload symptoms.
Summary: A, B, and D are incorrect as they do not directly address the primary concern of correcting low sodium levels in hyponatremia.
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. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition.
Incorrect choices:
A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it.
B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed.
D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.