Nokea
The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?
- A. Poor control of blood glucose levels
- B. Current of recent foot trauma
- C. Inappropriate foot care
- D. Advanced age
Correct Answer: D
Rationale: Step 1: Define nonmodifiable risk factors - these are factors that cannot be changed or controlled by the individual.
Step 2: Advanced age is a nonmodifiable risk factor as it is determined by genetics and time.
Step 3: Poor control of blood glucose levels, foot trauma, and inappropriate foot care are modifiable risk factors that can be managed through lifestyle changes or medical interventions.
Summary: Choice D is correct because advanced age is a nonmodifiable risk factor for diabetes mellitus, while the other choices involve factors that can be modified through appropriate actions.
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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. This is because soap can irritate the skin, leading to skin breakdown in a client at risk for impaired skin integrity due to radiation therapy. Avoiding soap helps to prevent further damage to the skin.
Choice B is incorrect as talcum powder can further irritate the skin and should be avoided. Choice C is not relevant to preventing skin integrity issues. Choice D is incorrect because thoracic skin markings should not be removed as they are essential for accurate radiation delivery.
What is the primary purpose of validation as a part of assessment?
- A. To identify data to be validated
- B. To establish an effective nurse–client communication
- C. To maintain effective relationships with coworkers
- D. To plan appropriate nursing care
Correct Answer: D
Rationale: The primary purpose of validation in assessment is to ensure that the data collected is accurate and reliable to plan appropriate nursing care. Validation helps confirm the accuracy of data, identify inconsistencies, and ensure that the information gathered is trustworthy. By verifying the data, nurses can make informed decisions and tailor individualized care plans to meet the patient's needs effectively. Choices A, B, and C are incorrect because they do not directly relate to the purpose of validation in assessment. Choice A focuses on the identification of data, not the purpose of validation. Choice B and C pertain to communication and relationships, which are important but not the primary purpose of validation in the assessment process.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale:
1. Safety: Recording vital signs is crucial for patient safety.
2. Accountability: The nurse is ultimately responsible for ensuring vital signs are documented accurately.
3. Communication: It is essential for the nurse to communicate with the NAP to address the missed vital signs.
4. Corrective Action: Asking the NAP to record vital signs before administering medications ensures proper monitoring.
5. Patient-Centered Care: Prioritizing patient well-being by ensuring vital signs are up-to-date.
Summary:
A: Incorrect. Administering medications without vital sign assessment is unsafe.
B: Incorrect. Reviewing vital signs upon return does not address the immediate need for accurate documentation.
D: Incorrect. Omitting vital signs compromises patient safety and violates standard nursing practice.
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.
Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
- A. Restrict fluid intake
- B. Ensure that the client avoids prolonged sitting
- C. Position lower extremities below level of heart
- D. Instruct the client to avoid leg exercises
Correct Answer: C
Rationale: The correct answer is C: Position lower extremities below level of heart. This intervention helps improve blood flow and perfusion to the lower extremities by utilizing gravity to assist in venous return. This is crucial for clients at risk for ineffective tissue perfusion post-cardiac surgery.
A: Restricting fluid intake may lead to dehydration, which can worsen tissue perfusion.
B: Ensuring the client avoids prolonged sitting is important for preventing blood clots, but it does not directly address tissue perfusion.
D: Instructing the client to avoid leg exercises may hinder circulation and exacerbate issues related to tissue perfusion.