Nokea
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: Objective data in nursing refers to measurable and observable information. Respirations at 16 per minute are a specific, quantifiable measurement that the nurse can directly observe, making it objective data. This information is vital for assessing the patient's respiratory status accurately.
Choice A is incorrect because stating "doesn't feel good" is a subjective statement based on the patient's perception and cannot be directly measured or observed. Choice B, reporting a headache, is also subjective as it relies on the patient's description of their symptoms. Choice D, being nauseated, is subjective as well, as it is a symptom reported by the patient and not a quantifiable measurement.
In summary, choice C is correct as it represents objective data due to its quantifiable and observable nature, while the other choices are subjective and based on the patient's perceptions or feelings.
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Which patient should be monitored most closely for dehydration?
- A. The 50-year-old with an ileostomy
- B. The 72-year-old with diabetes mellitus
- C. The 19-year-old with chronic asthma
- D. The 28-year-old with a broken femur
Correct Answer: A
Rationale: The correct answer is A, the 50-year-old with an ileostomy, should be monitored most closely for dehydration. Patients with an ileostomy have a higher risk of dehydration due to increased fluid loss through the stoma. Monitoring their fluid intake, output, electrolyte levels, and signs of dehydration is crucial to prevent complications. The other choices are less likely to experience severe dehydration compared to the patient with an ileostomy. The 72-year-old with diabetes mellitus may be at risk for dehydration, but it is not as high a risk as the patient with an ileostomy. The 19-year-old with chronic asthma and the 28-year-old with a broken femur are not as directly related to dehydration compared to the patient with an ileostomy.
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
- A. Fluid intake of less than 2,500mL in 24 hours
- B. Urine output of more than 200mL/hour
- C. Blood pressure of 90/50mmHg
- D. Pulse rate of 126 beats/min
Correct Answer: A
Rationale: The correct answer is A because successful treatment of diabetes insipidus aims to reduce excessive urine output and dehydration. A fluid intake of less than 2,500mL in 24 hours indicates proper control of fluid balance.
Choice B is incorrect because urine output of more than 200mL/hour suggests ongoing excessive fluid loss, which is not indicative of successful treatment.
Choice C is incorrect as a blood pressure of 90/50mmHg is low and may indicate hypotension, which is not a specific indicator of successful diabetes insipidus treatment.
Choice D is incorrect because a pulse rate of 126 beats/min is not a direct marker of diabetes insipidus treatment success.
In summary, the correct indicator of successful treatment of diabetes insipidus is a reduction in fluid intake, option A, as it signifies improved fluid balance and hydration status.
Nurse Kara is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: The correct answer is C. Washing feet in hot water is not part of diabetic foot care as it can lead to burns or skin damage. A: Properly fitting shoes help prevent injuries. B: Trimming toenails straight reduces risk of ingrown nails. D: Wearing shoes on hot surfaces protects feet from burns or injuries. Overall, C is incorrect due to its potential harm to the client's feet.
Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
- A. Set priorities for patient care.
- B. Determine whether outcomes or standards are met.
- C. Ambulate patient 25 feet in the hallway.
- D. Document results of goal achievement.
Correct Answer: A
Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.
A client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?
- A. Persistent nausea
- B. Indigestion
- C. Rash
- D. Chronic ache or pain
Correct Answer: D
Rationale: The correct answer is D: Chronic ache or pain. Persistent cough and chronic ache or pain are both common warning signs of cancer. Chronic pain can be a symptom of various types of cancer, signaling the presence of a tumor or cancerous growth. It is important for the client to seek medical evaluation to rule out any underlying serious condition.
A: Persistent nausea is not typically considered a common warning sign of cancer. While it can be a symptom in certain types of cancer or due to treatment side effects, it is not as prominent as chronic ache or pain.
B: Indigestion is a common symptom that can be caused by various non-cancer-related issues such as dietary habits, stress, or gastrointestinal disorders. It is not typically considered a direct warning sign of cancer.
C: Rash is generally not a common warning sign of cancer. Rashes are more commonly associated with skin conditions, allergic reactions, or infections rather than being an indicator of cancer.