Nokea
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow’s hierarchy of basic human needs, is appropriate for what level of needs?
- A. Physiologic
- B. Safety
- C. Love and belonging
- D. Self-actualization
Correct Answer: A
Rationale: The correct answer is A: Physiologic. Impaired Gas Exchange pertains to the basic physiological need for oxygenation, which is fundamental for survival. Maslow's hierarchy states that physiological needs are the most fundamental and must be met before progressing to higher-level needs. Safety, love and belonging, and self-actualization are higher-level needs compared to physiological needs. Therefore, Impaired Gas Exchange aligns with the physiological level of needs in Maslow's hierarchy.
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The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:
- A. increasing saturated fat intake and fasting in the afternoon.
- B. increasing intake of vitamins B and D and taking iron supplements.
- C. eating a candy bar if light-headedness occurs.
- D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Correct Answer: D
Rationale: The correct answer is D because a low-carbohydrate, high-protein diet helps stabilize blood sugar levels and prevents hypoglycemic episodes. Carbohydrates cause rapid spikes and drops in blood sugar, while protein helps maintain stable levels. Avoiding fasting also helps regulate blood sugar. Choice A is incorrect as increasing saturated fat and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron do not directly address hypoglycemia. Choice C is incorrect as relying on sugary foods like candy bars can lead to further blood sugar imbalances.
When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?
- A. When the client’s color does not improve
- B. When the client level of consciousness decreases
- C. When the client is in a state of respiratory arrest
- D. When the client cannot effectively use the diaphragm
Correct Answer: C
Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. Risk nursing diagnosis
- B. Actual nursing diagnosis
- C. Possible nursing diagnosis
- D. Wellness diagnosis
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, such as signs and symptoms exhibited by the patient. This helps in identifying the specific health issues that the patient is currently experiencing. In contrast, a risk nursing diagnosis is focused on potential health problems that the patient may develop in the future. Possible nursing diagnosis involves uncertain or unclear health issues that require further assessment. Wellness diagnosis is aimed at enhancing health and promoting well-being, rather than addressing existing health problems. Therefore, the presence of major defining characteristics is crucial in confirming an actual nursing diagnosis.
Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
- A. 10% dextrose and saline
- B. 5% dextrose and water
- C. 5% dextrose and water with 60 mEq
- D. Distilled water KCl
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.
A client has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chorambucil might this reaction occur?
- A. Immediately
- B. 2 to 3 weeks
- C. 1 week
- D. 1 month
Correct Answer: B
Rationale: The correct answer is B: 2 to 3 weeks. Alopecia (hair loss) is a common adverse reaction of chlorambucil, typically occurring 2 to 3 weeks after the first administration. This is due to the drug's effect on rapidly dividing cells, including hair follicles. Immediate onset (Choice A) is unlikely as it takes time for the drug to affect hair growth. One week (Choice C) is too soon for alopecia to manifest. One month (Choice D) is too long as alopecia usually occurs earlier. Therefore, the correct window for alopecia onset after chlorambucil administration is 2 to 3 weeks.