Nokea
The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
- A. Use commercial preparations to remove
- B. Wash and inspect the feet daily
- C. Walk barefoot at least once each daily
- D. Cut the toenails by rounding edges
Correct Answer: B
Rationale: The correct answer is B: Wash and inspect the feet daily. This is important for clients with diabetes mellitus to prevent complications like foot ulcers. Daily foot care helps detect any issues early. Choice A is incorrect as it is not recommended to use commercial preparations without medical advice. Choice C is incorrect as walking barefoot can increase the risk of injury and infection. Choice D is incorrect as cutting toenails by rounding edges can lead to ingrown toenails, which can be dangerous for clients with diabetes.
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A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
- A. The client’s diet
- B. The client’s family member’s history of
- C. The client’s drug history chronic diseases
- D. The client’s ability to produce antibodies
Correct Answer: D
Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly.
A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function.
B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system.
C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
- A. Sore throat
- B. Acute pain
- C. Sleep apnea
- D. Heart failure
Correct Answer: B
Rationale: The correct answer is B: Acute pain. The NANDA-I (North American Nursing Diagnosis Association International) approved diagnosis must meet specific criteria related to patient assessment data, defining characteristics, and related factors. Acute pain is a well-defined nursing diagnosis with specific defining characteristics and related factors, making it a suitable and approved option for inclusion in a patient's care plan. Sore throat, sleep apnea, and heart failure do not meet the criteria for a NANDA-I approved diagnosis as they lack the specificity and comprehensive assessment data required for a nursing diagnosis.
Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
- A. Hyperventilating James with 100% oxygen before and after suctioning
- B. Instilling 3 to 5 ml normal saline to loosen up secretion
- C. Applying suction during catheter withdrawal
- D. Suction the client every hour
Correct Answer: A
Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows:
1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity.
2. Oxygen toxicity can result in lung damage and other complications.
3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations.
Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.
The most effective pharmacologic agent for the treatment of Parkinson’s disease is:
- A. Levodopa
- B. Selegilene
- C. Permax
- D. Symmetrel
Correct Answer: A
Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for treating Parkinson's disease because it is converted to dopamine in the brain, replenishing the deficient dopamine levels in Parkinson's patients. Selegiline and Symmetrel are also used in treating Parkinson's, but they are typically used as adjunctive therapy rather than the primary treatment. Permax has been withdrawn from the market due to safety concerns, making it an incorrect choice.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
- A. Platelet count, prothrombin time, and partial thromboplastin time
- B. Platelet count, blood glucose levels, and white blood cell (WBC) count
- C. Thrombin time, calcium levels, and potassium levels
- D. Fibrinogen level, WBC, and platelet count
Correct Answer: A
Rationale: The correct answer is A: Platelet count, prothrombin time, and partial thromboplastin time. These parameters are essential in monitoring DIC because platelet count reflects the risk of bleeding, while prolonged prothrombin time and partial thromboplastin time indicate impaired clotting function, which is characteristic of DIC.
Explanation for why other choices are incorrect:
- Choice B: Blood glucose levels and WBC count are not specific indicators for DIC monitoring.
- Choice C: Thrombin time, calcium levels, and potassium levels do not directly assess clotting abnormalities associated with DIC.
- Choice D: While fibrinogen level is important in DIC, WBC count alone is not a specific indicator for monitoring DIC.