Nokea
The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?
- A. Cognitive
- B. Interpersonal
- C. Psychomotor
- D. Judgmental
Correct Answer: C
Rationale: The correct answer is C: Psychomotor. The nurse is demonstrating psychomotor skills by inserting an IV catheter correctly. Psychomotor skills involve the ability to perform physical tasks effectively and efficiently. This skill requires coordination, dexterity, and precision. The other choices are incorrect because:
A: Cognitive skills involve thinking, analyzing, and problem-solving.
B: Interpersonal skills involve communication and interaction with others.
D: Judgmental skills involve critical thinking and decision-making.
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After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
- A. Esophageal carcinoma
- B. Laryngeal carcinoma
- C. Pituitary carcinoma
- D. Colorectal carcinoma
Correct Answer: C
Rationale: Rationale:
1. Transsphenoidal adenohypophysectomy is the surgical removal of the pituitary gland's adenohypophysis.
2. The procedure is used to treat pituitary tumors, which can be benign or malignant, but commonly referred to as pituitary adenomas.
3. Pituitary adenomas may secrete hormones excessively, leading to various endocrine disorders.
4. Hormone replacement therapy is required post-surgery to manage hormonal deficiencies.
5. Therefore, the correct answer is C (Pituitary carcinoma).
Summary:
A, B, and D are incorrect as they do not involve the pituitary gland, which is the primary target of a transsphenoidal adenohypophysectomy.
Which of the ff is an initial sign or symptom of acute bronchitis?
- A. Nonproductive cough
- B. Anorexia
- C. Labored breathing
- D. Gastric ulceration
Correct Answer: A
Rationale: Step-by-step rationale:
1. Acute bronchitis is characterized by inflammation of the bronchial tubes.
2. An initial sign of acute bronchitis is a nonproductive cough due to irritation of the bronchial tubes.
3. Anorexia and labored breathing may occur later as the condition progresses.
4. Gastric ulceration is not typically associated with acute bronchitis.
Therefore, choice A (Nonproductive cough) is the correct answer as it aligns with the characteristic symptom of acute bronchitis, while the other choices are not typically observed in the initial stages of the condition.
An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client’s fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.
A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?
- A. Keep all side rails down at all times.
- B. Encourage patient to remain in bed most of the shift.
- C. Place patient in room away from the nurses’ station if possible.
- D. Assist patient into and out of bed every 4 hours or as tolerated.
Correct Answer: D
Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support.
A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls.
B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls.
C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies.
In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?
- A. The client is maintained on strict bed rest
- B. The head of the bed is at 30-degree angle
- C. The client receives a complete bed bath each morning
- D. The nurse checks the applicator’s position every 4 hours
Correct Answer: B
Rationale: The correct answer is B because maintaining the head of the bed at a 30-degree angle can cause the radioactive material to shift within the client's body, increasing the risk of radiation exposure. This position should be avoided to prevent displacement of the applicator.
A: Strict bed rest is appropriate to minimize movement and dislodgement of the applicator, ensuring proper treatment delivery.
C: Providing a bed bath does not pose a radiation hazard as long as proper precautions are taken.
D: Checking the applicator's position every 4 hours is essential for monitoring and ensuring it remains in place to deliver the intended treatment.