Nokea
The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?
- A. Offer psychological support for depression.
- B. Offer high-calorie, high-protein dietary choices.
- C. Administer prescribed opioids to relieve pain as needed.
- D. Teach about the need to avoid scratching any pruritic areas.
Correct Answer: C
Rationale: The correct answer is to administer prescribed opioids to relieve pain as needed. Pain management is the highest priority in this scenario as effective pain control is essential for the patient's overall well-being. Pain relief will not only improve the patient's comfort but also enhance their ability to eat, follow dietary recommendations, and be open to psychological support. Offering psychological support for depression (Choice A) is important but addressing pain takes precedence. While providing high-calorie, high-protein dietary choices (Choice B) is crucial, it is secondary to managing pain. Teaching about the need to avoid scratching pruritic areas (Choice D) is relevant but not the highest priority in this situation where pain management is critical for the patient's quality of life.
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Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?
- A. Teach about symptoms of variceal bleeding
- B. Draw blood for hepatitis serology testing
- C. Discuss the need to increase caloric intake
- D. Review the patient's current medication list
Correct Answer: D
Rationale: The correct action for a patient diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD) would be to review the patient's current medication list. This is important because certain medications can increase the risk for NAFLD, and they should be identified and possibly eliminated. Teaching about symptoms of variceal bleeding is not necessary as variceal bleeding is not a concern in a patient with asymptomatic NAFLD. Drawing blood for hepatitis serology testing is not indicated as NAFLD is not associated with hepatitis. Discussing the need to increase caloric intake is also not appropriate since weight loss is usually recommended in the management of NAFLD.
To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
- A. Assist the client in using the bedside commode.
- B. Administer stool softeners daily as prescribed.
- C. Administer antidysrhythmics prn as ordered.
- D. Maintain the client on strict bed rest.
Correct Answer: B
Rationale: Administering stool softeners daily is crucial to prevent straining during defecation, which can lead to the Valsalva maneuver. Straining can increase intrathoracic pressure, decrease venous return to the heart, and reduce cardiac output, potentially worsening the client's condition. If constipation occurs, the use of laxatives may be necessary to avoid straining. Administering antidysrhythmics on an as-needed basis is not indicated for preventing the Valsalva maneuver; they are used to manage dysrhythmias. Strict bed rest is not necessary and may lead to complications such as deconditioning, DVT, and respiratory issues in the absence of specific medical indications.
Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?
- A. The patient's urine is bright yellow
- B. The patient's stools are tan colored
- C. The patient has increased pain after eating
- D. The patient complains of chronic heartburn
Correct Answer: B
Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.
The nurse is caring for a 10-year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement is:
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct Answer: A
Rationale: For a child of this age, this is adequate output, yet does not suggest overload. Disruption
of sodium-ATPase activity presumably causes an intracellular sodium shift which
contributes to hypovolemia and cellular edema. Heat injury also initiates the release of
inflammatory and vasoactive mediators. These mediators are responsible for local
vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase
in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and
plasma proteins between the intravascular and interstitial spaces.
A client in the ICU has been intubated and placed on a ventilator. The physician orders synchronous intermittent mandatory ventilation (SIMV). Which statement best describes the work of this mode of ventilation?
- A. The ventilator delivers a set rate and tidal volume regardless of whether the client is attempting to breathe
- B. The ventilator coordinates delivered breaths with the client's respiratory efforts
- C. The ventilator provides a supplemental breath for every third breath of the client
- D. The ventilator provides breaths during the expiratory phase of the client's respirations
Correct Answer: B
Rationale: Synchronous intermittent mandatory ventilation (SIMV) is a ventilation mode that coordinates delivered breaths with the client's own respiratory efforts. This mode allows the client to initiate breaths, with the ventilator providing preset breaths at a controlled rate and volume. Option A is incorrect because in SIMV, the ventilator syncs with the client's respiratory efforts. Option C is incorrect as it does not accurately depict the way SIMV works. Option D is also incorrect as SIMV does not specifically provide breaths during the expiratory phase of the client's respirations. Therefore, the correct answer is B, where the ventilator coordinates breath delivery with the client's breathing efforts.