Nokea
The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
- A. Protocols are guidelines to follow that replace the nursing care plan. Protocols assist the clinician in making decisions and choosing interventions for specific
- B. health care problems or conditions. Protocols are policies designating each nurse’s duty according to standards of care and a
- C. code of ethics.
- D. Protocols are prescriptive order forms that help individualize the plan of care.
Correct Answer: A
Rationale: The correct answer is A because protocols are indeed guidelines that assist clinicians in decision-making and choosing interventions for specific health care problems. This definition accurately reflects the purpose and function of protocols in nursing practice.
Option B is incorrect as it describes protocols as policies related to nurses' duties and standards of care, which is more aligned with job descriptions and policies rather than protocols.
Option C is incorrect as it relates protocols to a code of ethics, which is a separate concept that guides ethical decision-making and behavior in nursing practice.
Option D is incorrect as it inaccurately describes protocols as prescriptive order forms, which are actually separate from protocols and are used for medication administration and treatment orders.
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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,
The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse’s best response?
- A. “Yes, all pregnant women must have the test.”
- B. “If you do not have multiple sex partners or inject drugs, it is not necessary.”
- C. “Governmental guidelines require an HIV test for all pregnant woman.”
- D. “After voluntary pretest counseling, you decide whether HIV testing should be done.”
Correct Answer: A
Rationale: Rationale for Correct Answer (A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby.
Summary of Incorrect Choices:
B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors.
C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby.
D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.
A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client’s history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:
- A. Testosterone therapy during childhood
- B. Early onset of puberty
- C. Sexually transmitted disease
- D. Cryptorchidism
Correct Answer: D
Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer as the testicle does not descend into the scrotum during fetal development, increasing the risk of cancer development. Testosterone therapy during childhood (A) and early onset of puberty (B) are not directly linked to testicular cancer. Sexually transmitted diseases (C) typically do not increase the risk of testicular cancer. Therefore, choice D is the most relevant risk factor for testicular cancer in this scenario.
Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:
- A. Loosening constrictive clothing
- B. Opening the patient’s jaw and inserting a mouth gag
- C. Positioning the patient on his or her side with head flexed forward
- D. Providing for privacy
Correct Answer: B
Rationale: The correct answer is B because inserting a mouth gag during a convulsive seizure can obstruct the airway and pose a choking hazard. Step-by-step rationale: A: Loosening clothing helps improve ventilation. C: Positioning on the side with head flexed forward prevents aspiration. D: Providing privacy is important for patient dignity and confidentiality. B is incorrect as it can be harmful.
The nurse would expect which of the following would be included in the plan of care/
- A. Have the client drink at least 8 glases of water in the first day
- B. Administer NaHCO3 IV as per physician’s orders
- C. Continue sodium bicarbonate for nausea
- D. Monitor electrolytes for hypokalemia and hypocalcemia
Correct Answer: D
Rationale: Step 1: Monitoring electrolytes is essential to assess for potential imbalances due to the use of sodium bicarbonate, which can lead to hypokalemia and hypocalcemia.
Step 2: Hypokalemia and hypocalcemia can result in serious complications such as cardiac arrhythmias and muscle weakness.
Step 3: By monitoring electrolytes, the nurse can detect imbalances early and intervene promptly to prevent adverse effects.
Summary:
A: Drinking excessive water can lead to electrolyte imbalances and is not directly related to the use of sodium bicarbonate.
B: Administering NaHCO3 IV is not within the nurse's scope of practice and should be done based on physician's orders.
C: Continuing sodium bicarbonate for nausea may not be appropriate without monitoring electrolytes to prevent potential imbalances.