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The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
- A. Weights every day .
- B. Blood pressure every 15 minutes
- C. Urinary output every hour
- D. Extent of peripheral edema every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.
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Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
- A. Imbalanced nutrition:Less than body requirements related to poor intake
- B. Disturbed sleep pattern related to external stimuli
- C. Impaired skin integrity related to pruritus
- D. Pain related to sickle cell crisis
Correct Answer: D
Rationale: The correct answer is D: Pain related to sickle cell crisis. In a sickle cell crisis, the client experiences severe pain due to the sickling of red blood cells, which causes blockages in blood vessels. This pain is the hallmark symptom of sickle cell crisis and is a priority nursing diagnosis. The other choices are incorrect because they do not directly relate to the primary issue of sickle cell crisis. Imbalanced nutrition is not typically a priority during a crisis, disturbed sleep pattern is not a common symptom, and impaired skin integrity is not a prominent concern in sickle cell crisis.
Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?
- A. BUN and creatinine
- B. Hgb and Hct
- C. ABG
- D. Serum potassium
Correct Answer: C
Rationale: The correct answer is C: ABG. Monitoring ABG in Guillain-Barre Syndrome patients is crucial as they are at risk for respiratory complications like respiratory failure due to muscle weakness. ABG provides information on oxygenation, ventilation, and acid-base balance. Regular monitoring helps detect early signs of respiratory distress and guide appropriate interventions.
A: BUN and creatinine are important for assessing renal function, but they do not directly relate to acute complications in Guillain-Barre Syndrome.
B: Hgb and Hct are markers for anemia, which is not a common acute complication in Guillain-Barre Syndrome.
D: Serum potassium levels are important, but ABG monitoring takes precedence in patients with Guillain-Barre Syndrome due to the risk of respiratory issues.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
- A. Self-care deficient: Bathing/hygiene
- B. Dysfunctional grieving
- C. Ineffective cerebral tissue perfusion
- D. Risk for injury
Correct Answer: C
Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration.
Summary:
A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications.
B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue.
D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.
Which client has the highest risk of ovarian cancer?
- A. 30-year old woman taking contraceptives
- B. 45-year old woman who has never been pregnant
- C. 40-year old woman with three children
- D. 36-year old woman who had her first child at age 22
Correct Answer: B
Rationale: The correct answer is B: 45-year old woman who has never been pregnant. The risk of ovarian cancer increases with age and nulliparity (never having been pregnant) is a significant risk factor. The older a woman gets without having been pregnant, the higher her risk of developing ovarian cancer. The other choices do not have as high of a risk factor for ovarian cancer. Choice A, a 30-year old woman taking contraceptives, actually reduces the risk of ovarian cancer. Choice C, a 40-year old woman with three children, and choice D, a 36-year old woman who had her first child at age 22, both have lower risk factors compared to choice B.
Which action will the nurse take after the plan of care for a patient is developed?
- A. Place the original copy in the chart, so it cannot be tampered with or revised.
- B. Communicate the plan to all health care professionals involved in the patient’s care.
- C. File the plan of care in the administration office for legal examination. NursingStoreRN
- D. Send the plan of care to quality assurance for review.
Correct Answer: B
Rationale: The correct answer is B because after developing a plan of care, the nurse must communicate it to all healthcare professionals involved in the patient's care to ensure everyone is aware of the plan and can collaborate effectively. This promotes continuity of care and prevents errors.
Choice A is incorrect because the plan of care should not be placed in the chart to avoid tampering; it should be easily accessible for updates. Choice C is incorrect as filing in the administration office is unnecessary for routine care. Choice D is incorrect as sending the plan to quality assurance is not the immediate next step after developing the plan.