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To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should;
- A. Use aseptic technique for the insertion site.
- B. Use clean technique for cleansing connections and aseptic technique for the insertion site.
- C. Use sterile technique when cleansing the insertion site
- D. Close any leaks in the tubing with tape. SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Correct Answer: A
Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is necessary to prevent infection when accessing the intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field during the insertion process, reducing the risk of introducing pathogens. Using clean technique for cleansing connections (choice B) may introduce contaminants to the insertion site. Sterile technique for cleansing the insertion site (choice C) is not necessary and may be overly stringent. Closing leaks in the tubing with tape (choice D) does not address the prevention of infection at the insertion site.
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The nurse is caring for a patient with HIV. Which of the following foods would the nurse teach the patient is safe to eat to reduce the risk of infection?
- A. Raw fruits
- B. Raw vegetables
- C. Cooked vegetables
- D. Caesar dressing
Correct Answer: C
Rationale: The correct answer is C: Cooked vegetables. Cooking vegetables helps to kill harmful bacteria and parasites that may pose a risk of infection to an immunocompromised individual like a patient with HIV. Raw fruits (A) and raw vegetables (B) may carry pathogens that can be dangerous for someone with a weakened immune system. Caesar dressing (D) may contain raw eggs, which also pose a risk for infection. Therefore, choosing cooked vegetables is the safest option to reduce the risk of infection for the patient with HIV.
A patient’s serum sodium is within normal range. The nurse estimates that serum osmolality should be:
- A. Less than 136mOsm/kg
- B. Greater than 408mOsm/kg
- C. 280 to 295mOsm/kg
- D. 350 to 544mOsm/kg
Correct Answer: C
Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.
Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
- A. Set priorities for patient care.
- B. Determine whether outcomes or standards are met.
- C. Ambulate patient 25 feet in the hallway.
- D. Document results of goal achievement.
Correct Answer: A
Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
- A. Nurse monitors for chest pain and elevated low-density lipoprotein levels
- B. Nurse monitors for swelling and heaviness of legs
- C. Nurse monitors postural changes in BP
- D. Nurse monitors temperature for mild fever
Correct Answer: B
Rationale: The correct answer is B because monitoring for swelling and heaviness of legs is essential in preventing falls, which can be caused by conditions like edema or circulatory issues. Swollen or heavy legs can affect mobility and balance, increasing the risk of falls. This intervention helps identify potential issues early and implement preventive measures.
Choice A is incorrect as monitoring for chest pain and LDL levels pertains more to cardiovascular health than fall prevention. Choice C is incorrect because monitoring postural changes in BP is important for managing hypertension, not necessarily for preventing falls. Choice D is incorrect as monitoring temperature for mild fever is more related to identifying infections rather than preventing falls.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. The nurse chose this diagnosis based on the patient's chest x-ray results indicating lower lobe infiltrates, which directly affect gas exchange.
Choice A is incorrect because "ineffective breathing pattern" does not specifically address the underlying physiological issue of impaired gas exchange. Choice B is incorrect as it focuses on infection risk from the chest x-ray procedure, not the patient's medical condition. Choice C is incorrect as dehydration is not directly related to pneumonia and infiltrates.