Nokea
The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding
- B. Evaluate the calorie count of the 500-mg protein diet
- C. Assess the client's sacrum for dependent edema
- D. Monitor for a high serum albumin level
Correct Answer: C
Rationale: Assessing the client's sacrum for dependent edema is crucial in the care plan for nephritic syndrome as it is common due to protein loss. Dependent edema occurs as a result of decreased oncotic pressure from protein loss in the urine. Monitoring urine for bright-red bleeding (choice A) is more relevant to conditions like glomerulonephritis. Evaluating calorie count or protein intake (choice B) is important for other conditions but not specifically for nephritic syndrome. Monitoring for a high serum albumin level (choice D) is not typically part of the immediate care plan for nephritic syndrome.
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When does the nurse act as a client advocate?
- A. Pulling the curtain around the client's bed while changing a dressing
- B. Contacting the health care provider to request a meeting for the client
- C. Ensuring access to medical information by appropriate personnel only
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, 'All of the above.' Acting as a client advocate involves various actions to protect the client's rights and well-being. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity. Contacting the health care provider to request a meeting for the client facilitates communication and addresses the client's needs. Ensuring access to medical information by appropriate personnel only safeguards the client's confidentiality and privacy. Therefore, all the actions mentioned in choices A, B, and C are examples of a nurse acting as a client advocate, making D the correct answer.
The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?
- A. The assistant is putting the stockings on while the client is in the chair
- B. The assistant inserted two (2) fingers under the proximal end of the stocking
- C. The assistant elevated the feet while lying down to put on the stockings
- D. The assistant made sure the toes were warm after putting the stockings on
Correct Answer: A
Rationale: The correct answer is A. Compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is incorrect as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C is incorrect as elevating the feet while lying down is a correct technique for applying compression stockings. Choice D is incorrect as ensuring the toes are warm after putting the stockings on is a good practice for client comfort.
In which situation(s) can personal health information be disclosed?
- A. Compliance with legal proceedings
- B. For research purposes in limited circumstances
- C. To a family member or significant other in an emergency
- D. All of the above
Correct Answer: D
Rationale: Personal health information can be disclosed in various situations. Compliance with legal proceedings allows for disclosure under specific legal requirements. Disclosure for research purposes is permitted in limited circumstances with appropriate approvals. In emergencies, information can be shared with family members or significant others. Therefore, all of the choices are correct as they represent valid scenarios for disclosing personal health information.
During a synchronized cardioversion on a client in atrial fibrillation, when the machine is activated and there is a pause, what action should the nurse take?
- A. Wait until the machine discharges
- B. Shout "all clear" and don't touch the bed
- C. Make sure the client is all right
- D. Increase the joules and re-discharge
Correct Answer: B
Rationale: The correct action for the nurse to take when there is a pause after activating the machine for synchronized cardioversion on a client in atrial fibrillation is to shout "all clear" and not touch the bed. This step is crucial to ensure the safety of everyone present by warning them that the machine will discharge, preventing anyone from being inadvertently shocked. Waiting for the machine to discharge (choice A) is not recommended as it can lead to accidental injury. While ensuring the client is all right (choice C) is important, the immediate focus should be on safety during the procedure. Increasing the joules and re-discharging (choice D) without assessing the situation can pose risks to the client and the healthcare team.
Infection or inflammation of small sacs that protrude from the lumen of the colon is known as:
- A. Diverticulosis
- B. Diverticulitis
- C. Cholelithiasis
- D. Cholecystitis
Correct Answer: B
Rationale: Diverticulitis refers to the infection or inflammation of diverticula in the colon. Choice A, Diverticulosis, is the condition of having diverticula without inflammation. Choices C and D, Cholelithiasis and Cholecystitis, are related to the gallbladder and not the colon, making them incorrect in this context.