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The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient’s gastrointestinal tract is resuming normal function?
- A. Firm abdomen
- B. Presence of flatus
- C. Excessive thirst
- D. Absent bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Presence of flatus. This indicates normal gastrointestinal function post-bowel resection. Flatus production signifies peristalsis and passage of gas through the intestines, indicating that the bowels are working. A, firm abdomen, may indicate distention or ileus, not normal function. C, excessive thirst, is unrelated to bowel function. D, absent bowel sounds, may indicate ileus or bowel obstruction, not normal function.
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A patient’s chest x-ray examination indicates fluid in both lung bases. Which of the ff. signs or symptoms present during the nurse’s assessment most reflects these x-ray examination findings?
- A. Fatigue
- B. Peripheral edema
- C. Bilateral crackles
- D. Jugular vein distention
Correct Answer: C
Rationale: The correct answer is C, bilateral crackles. Fluid in both lung bases on x-ray indicates pulmonary edema, causing crackles on auscultation. Fatigue (A) is a nonspecific symptom. Peripheral edema (B) is a sign of fluid retention in the extremities, not lungs. Jugular vein distention (D) indicates increased central venous pressure, which is not specific to lung fluid.
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
- A. Cancerous lumps.
- B. Changes from previous self-examinations.
- C. Areas of thickness or fullness.
- D. Fibrocystic masses.
Correct Answer: A
Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.
An adult is on a clear liquid diet. Which food item can be offered/
- A. Milk
- B. Orange juice
- C. Jello
- D. Ice cream
Correct Answer: C
Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids and foods that are liquid at room temperature. Jello meets this criteria as it is a clear, easily digestible food. Milk (A) is not allowed on a clear liquid diet due to its opaque nature. Orange juice (B) contains pulp and is not considered clear. Ice cream (D) is a solid food and not permitted on a clear liquid diet. Therefore, Jello is the most suitable option for someone on a clear liquid diet.
A 45-year old female diabetic is displaying signs of irritability and irrational behavior during an office visit. The nurse observes visible tremors in the client’s hands. based on the client’s history and the nurse’s understanding of diabetes mellitus, the nurse interprets these findings to be signs of:
- A. hyperglycemia
- B. hyperglycemic hyperosmolar
- C. diabetic ketoacidosis (DKA) nonketosis (HHNK)
- D. hypoglycemia
Correct Answer: D
Rationale: The correct answer is D: hypoglycemia. In a diabetic patient, signs of irritability, irrational behavior, and visible tremors in the hands indicate low blood sugar levels, which is hypoglycemia. This is because the brain relies on glucose for energy, and when blood sugar levels drop too low, it can lead to neuroglycopenic symptoms such as confusion and tremors.
Explanation for why the other choices are incorrect:
A: hyperglycemia - High blood sugar levels typically present with symptoms such as frequent urination, increased thirst, and fatigue, not irritability and tremors.
B: hyperglycemic hyperosmolar - This condition is characterized by extremely high blood sugar levels and severe dehydration, leading to symptoms such as extreme thirst and confusion, not irritability and tremors.
C: diabetic ketoacidosis (DKA) nonketosis (HHNK) - These conditions are associated with high blood sugar levels and metabolic disturbances,
A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.)
- A. Observations of wound healing
- B. Daily blood pressure measurements
- C. Findings of respiratory rate and depth
- D. Completion of nursing interventions NursingStoreRN
Correct Answer: A
Rationale: The correct answer is A: Observations of wound healing. This is the correct evaluative measure because it directly assesses the patient's response to nursing care, indicating the effectiveness of interventions. Wound healing is a tangible and visible indicator of the patient's overall health status and the success of nursing interventions.
The other choices are incorrect:
B: Daily blood pressure measurements do not solely indicate a patient's response to nursing care. Blood pressure can be affected by various factors unrelated to nursing interventions.
C: Findings of respiratory rate and depth are important for assessing respiratory status but may not directly reflect the patient's response to nursing care.
D: Completion of nursing interventions is a process measure and does not provide direct insight into the patient's response to care.