Nokea
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: B
Rationale: Peritonitis is a serious and potentially life-threatening condition that can occur as a complication of malignant tumors. It is characterized by inflammation of the lining of the abdomen and can result in severe abdominal pain, tenderness, fever, and other symptoms. Prompt assessment of peritonitis symptoms is crucial for early detection and intervention to prevent further complications and improve patient outcomes. Assessing for peritonitis symptoms should be the priority in the nursing management plan to ensure timely and appropriate care for the client with malignant tumors.
You may also like to solve these questions
Why are rectal temperatures not recommended in the newborn?
- A. They are inaccurate.
- B. They do not reflect core body temperature.
- C. They can cause perforation of rectal mucosa.
- D. They take too long to obtain an accurate reading.
Correct Answer: C
Rationale: Rectal temperatures are not recommended in newborns because they can potentially cause perforation of the rectal mucosa. Newborns have fragile, delicate tissues in the rectal area, and the insertion of a rectal thermometer may lead to injury or damage to the mucosal lining. It is important to exercise caution and use alternative methods for taking temperatures in newborns to avoid any harm or discomfort.
What is most likely the underlying physiology of primary enuresis?
- A. Psychogenic stress
- B. Delayed bladder maturation
- C. Urinary tract infection
- D. Vesicoureteral reflux
Correct Answer: B
Rationale: Primary enuresis refers to involuntary wetting during sleep in children who have never been consistently dry at night. The most likely underlying physiology of primary enuresis is delayed bladder maturation. This means that the child's bladder is not yet able to hold urine for the entire night, leading to bedwetting episodes. As children age, their bladder capacity increases and their ability to remain dry at night improves. In most cases, primary enuresis resolves on its own as the child's bladder matures. It is important for parents and caregivers to provide support and reassurance to the child during this time.
An adult has and IV line in the right forearm infusing D5 ½ NS with 20 mEq of potassium at 75 ml/h. which statement would be a correct report from the RN?
- A. The potassium bag is piggybacked into the dextrose at 75ml/h
- B. The clamp should be closed below the D5 ½ NS bag
- C. Potassium is on the secondary line
- D. 75 ml infuse in one hour
Correct Answer: A
Rationale: The correct report from the RN in this situation would be option A. This report accurately describes the situation by mentioning that the potassium bag is piggybacked into the dextrose at 75 ml/h, stating that the clamp should be closed below the D5 ½ NS bag, and clarifying that potassium is on the secondary line. Additionally, the statement that 75 ml will infuse in one hour is also correct based on the infusion rate provided in the question. Therefore, option A is the most appropriate and accurate report to provide in this scenario.
Which of the following instructions would Nurse Courtney include in a teaching plan that focuses on initial prevention for Sheri who is diagnosed with rheumatic fever?
- A. Treating streptococcal throat infections with an antibiotic
- B. Giving penicillin to patients with rheumatic fever
- C. Using corticosteroid to reduce inflammation
- D. Providing an antibiotic before dental work
Correct Answer: A
Rationale: The most appropriate instruction in a teaching plan focusing on initial prevention for Sheri, who is diagnosed with rheumatic fever, would be treating streptococcal throat infections with an antibiotic (Choice A). Rheumatic fever is often preceded by a group A streptococcal infection, such as strep throat. Prompt treatment of streptococcal infections with antibiotics can help prevent the development of rheumatic fever and its complications. Therefore, this instruction emphasizes the importance of treating the initial infection to prevent the occurrence of rheumatic fever in individuals like Sheri who are at risk. Choices B, C, and D are not specific to the initial prevention of rheumatic fever but may be more related to the management or treatment of established cases.
The client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/ml. Which of the following symptoms would be expected as a result of this laboratory result?
- A. Nystagmus
- B. No symptoms, because this is normal
- C. Tachycardia therapeutic level
- D. Slurred speech
Correct Answer: A
Rationale: A phenytoin blood level of 35 mcg/ml is considered to be above the therapeutic range (usually 10-20 mcg/ml for phenytoin). At this elevated level, the client is at risk for phenytoin toxicity. Symptoms of phenytoin toxicity include nystagmus (rapid, involuntary eye movements), as well as other symptoms such as confusion, slurred speech, ataxia, and tremors. Tachycardia is not typically associated with phenytoin toxicity. Therefore, the expected symptom in this case would be nystagmus.