Nokea
The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
- A. “Never suction your tracheostomy; you might damage your trachea.”
- B. “”You should not feel bad about the tracheostomy – you should be feel lucky to be alive.”
- C. “Be sure to protect your tracheostomy from pollutants such as powders, hair and chemicals.”
- D. “Your tracheostomy will be cleaned each time you visit your doctor.”
Correct Answer: C
Rationale: The correct answer is C: “Be sure to protect your tracheostomy from pollutants such as powders, hair, and chemicals.” This instruction is appropriate because keeping the tracheostomy site clean and free from pollutants is crucial in preventing infections and complications. Powders, hair, and chemicals can lead to irritation and blockages, increasing the risk of infection.
Explanation of why other choices are incorrect:
A: “Never suction your tracheostomy; you might damage your trachea.” - This is incorrect because suctioning is a necessary part of tracheostomy care to clear secretions and ensure proper breathing.
B: “You should not feel bad about the tracheostomy – you should feel lucky to be alive.” - This is incorrect as it does not provide practical instructions for tracheostomy care and may not address the patient's emotional concerns adequately.
D: “Your tracheostomy will be cleaned each time you visit your doctor.” - This is
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Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because the nurse is using data validation by comparing the time of the last dressing change with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and relevant information. By assessing both the time of the last dressing change and the characteristics of the drainage, the nurse is validating the need for the intervention.
Option B is incorrect because administering pain medicine based solely on a patient's report of increased pain without further validation does not demonstrate data validation. Option C is incorrect as the nurse immediately requesting an order of potassium without further assessment of the patient's condition is not an example of data validation. Option D is incorrect as elevating a leg cast based solely on a patient's report of decreased mobility without further assessment does not involve data validation.
Charles is started on chemotherapy, which is aimed at restoring dopaminergic activities. An example of such a drug is:
- A. Artane
- B. Elavil
- C. Benadryl
- D. Dopar
Correct Answer: D
Rationale: The correct answer is D: Dopar. Dopar is a drug that increases dopamine levels by converting into dopamine in the brain. This directly restores dopaminergic activities. Artane (A) is an anticholinergic used for Parkinson's symptoms, Elavil (B) is a tricyclic antidepressant, and Benadryl (C) is an antihistamine, none of which directly target dopaminergic activities like Dopar does.
Antihistamines are used cautiously in older men with prostatic hypertrophy for which of the ff reasons?
- A. Because the clients may experience increased drowsiness
- B. Because these clients may experience difficulty voiding
- C. Because these clients face a greater risk of cardiac arrest
- D. Because these clients have a lower autoimmune response CARING FOR CLIENTS WITH AIDS
Correct Answer: B
Rationale: The correct answer is B: Because these clients may experience difficulty voiding. Antihistamines can worsen urinary symptoms in men with prostatic hypertrophy by causing urinary retention. This is due to the anticholinergic effects of antihistamines, which can lead to decreased bladder contraction and difficulty in voiding. Increased drowsiness (choice A) is a common side effect of antihistamines but is not specific to older men with prostatic hypertrophy. Choice C, greater risk of cardiac arrest, is not directly related to the use of antihistamines in older men with prostatic hypertrophy. Choice D, lower autoimmune response in clients with AIDS, is unrelated to the use of antihistamines in older men with prostatic hypertrophy.
A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600mg PO every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?
- A. Dysuria
- B. Tinnitus
- C. Leg cramps
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Tinnitus. Aspirin can cause tinnitus (ringing in the ears) as an adverse drug reaction, which can indicate potential ototoxicity. Tinnitus is an important side effect that should be reported promptly to the physician to prevent further auditory complications. Dysuria (A), leg cramps (C), and constipation (D) are not typically associated with aspirin use and are less urgent compared to tinnitus. Reporting these side effects may still be necessary but are not as critical as tinnitus in this scenario.
The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
- A. adenohypohysis.
- B. alpha cells of the pancreas.
- C. beta cells of the pancreas.
- D. parafollicular cells of the thyroid.
Correct Answer: C
Rationale: Rationale:
1. Insulin is a hormone produced by beta cells of the pancreas.
2. Beta cells are responsible for monitoring blood glucose levels and secreting insulin in response to high glucose levels.
3. Insulin helps regulate blood glucose by facilitating glucose uptake into cells.
4. Adenohypophysis secretes other hormones, not insulin.
5. Alpha cells of the pancreas secrete glucagon, not insulin.
6. Parafollicular cells of the thyroid secrete calcitonin, not insulin.
Summary:
Choice C is correct because insulin is indeed secreted from the beta cells of the pancreas. Choices A, B, and D are incorrect as they do not secrete insulin or are related to other hormones.