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The nurse understands that for the parathyroid hormone to exert its effect, what must be present?
- A. Decreased phosphate level
- B. Functioning thyroid gland
- C. Adequate vitamin D level
- D. Increased calcium level
Correct Answer: D
Rationale: The correct answer is D: Increased calcium level. Parathyroid hormone functions to increase blood calcium levels. When calcium levels are low, the parathyroid gland releases PTH to stimulate the release of calcium from bones and increase calcium absorption from the intestines and kidneys. This helps to maintain normal calcium levels in the blood. Choices A, B, and C are incorrect because decreased phosphate level, functioning thyroid gland, and adequate vitamin D level are not direct requirements for the action of parathyroid hormone.
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Which patient would benefit most from a capped IV catheter that is used intermittently rather than continuously?
- A. The patient with pneumonia who needs fluids and antibiotics.
- B. The patient who has had major blood loss after a motor vehicle accident.
- C. The young child who is dehydrated.
- D. The elderly patient who is receiving a diuretic for fluid overload.
Correct Answer: D
Rationale: The correct answer is D, the elderly patient receiving a diuretic for fluid overload. This patient would benefit most from a capped IV catheter used intermittently because diuretics can lead to fluctuations in fluid balance that require careful monitoring and adjustment of IV fluids. By using the catheter intermittently, healthcare providers can better control the amount of fluid administered to prevent electrolyte imbalances.
Option A is incorrect because a patient with pneumonia requiring fluids and antibiotics would likely benefit from a continuous IV to maintain stable levels of medications and hydration. Option B is incorrect as a patient with major blood loss would require continuous IV fluids to restore blood volume. Option C is incorrect as a dehydrated young child would also benefit from continuous IV fluids to rehydrate effectively.
A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
- A. patients.” “If the nursing department uses this system, communication among nurses who work
- B. throughout the hospital may be enhanced.” “We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our
- C. unit.” “The NIC system provides one way to improve safe and effective documentation in the
- D. hospital’s electronic health record.”
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
- A. Make sure he drinks 8 glasses of water a day.
- B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
- C. Look for signs of hyperchloremia
- D. Observe for neurologic changes
Correct Answer: B
Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications.
A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances.
C: Hyperchloremia is not a common concern in this scenario based on the given lab values.
D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.
A post-TURP patient experiences dribbling following removal of his catheter. Which action should the nurse take?
- A. Have him restrict fluid intake to 1000 mL/day
- B. Teach him to perform Kegel’s exercises 10 to 20 times per hour
- C. Reinsert the Foley catheter until he regains urinary control
- D. Reassure him that incontinence never lasts more than a few days
Correct Answer: B
Rationale: The correct answer is B: Teach him to perform Kegel's exercises 10 to 20 times per hour. This is the appropriate action because Kegel's exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling post-TURP. Restricting fluid intake (A) is not necessary and may lead to dehydration. Reinserting the Foley catheter (C) is not recommended as it can increase the risk of infection. Reassuring the patient (D) without providing any intervention is not addressing the issue. Teaching Kegel's exercises is the most effective and non-invasive approach to manage post-TURP dribbling.
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
- A. Yearly after age 40
- B. After the birth of the first child and every 2 years thereafter
- C. After the first menstrual period and annually thereafter
- D. Every 3 years between ages 20 and 40 and annually thereafter
Correct Answer: A
Rationale: The correct answer is A: Yearly after age 40. This recommendation aligns with the American Cancer Society guidelines that suggest women should start getting annual mammograms at age 40. This age is important as it is when the risk of breast cancer increases. Yearly screenings help in early detection and better treatment outcomes. The other choices (B, C, D) are incorrect because they do not follow the ACS guidelines. Option B is incorrect as it does not specify an age for starting mammograms. Option C is incorrect as it suggests starting after the first menstrual period, which might be too early. Option D is incorrect as it recommends screenings every 3 years between ages 20 and 40, which is not in line with the ACS recommendation for yearly screenings after age 40.