Nokea
To use the nursing process correctly, what must the nurse do first?
- A. Obtain information about the client
- B. Develop a care plan
- C. Implement interventions
- D. Evaluate the client's outcomes
Correct Answer: A
Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.
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A client with asthma is prescribed a corticosteroid inhaler. Which instruction should the nurse provide to the client to prevent a common side effect of this medication?
- A. Use the inhaler only when experiencing asthma symptoms.
- B. Rinse the mouth with water after using the inhaler.
- C. Increase fluid intake while using the inhaler.
- D. Avoid eating or drinking for 30 minutes after using the inhaler.
Correct Answer: B
Rationale: The correct instruction for the client using a corticosteroid inhaler to prevent a common side effect is to rinse the mouth with water after using the inhaler. Corticosteroid inhalers can lead to oral thrush, a fungal infection in the mouth. Rinsing the mouth helps reduce the risk of developing oral thrush. Choices A, C, and D are incorrect because using the inhaler only when experiencing symptoms, increasing fluid intake, or avoiding eating/drinking for 30 minutes after use are not directly related to preventing oral thrush, which is the common side effect associated with corticosteroid inhalers.
During an assessment, a healthcare professional is evaluating a client who has been on bed rest for the past month. Which of the following findings should the healthcare professional identify as an indication that the client has developed thrombophlebitis?
- A. bladder distention
- B. decreased blood pressure
- C. calf swelling
- D. diminished bowel sounds
Correct Answer: C
Rationale: Calf swelling, redness, and tenderness are classic signs of thrombophlebitis. The swelling occurs due to the formation of a blood clot in the deep veins of the calf, leading to inflammation and potential obstruction of blood flow. Bladder distention (Choice A) is more indicative of urinary retention, decreased blood pressure (Choice B) can be seen in conditions like shock, and diminished bowel sounds (Choice D) may suggest gastrointestinal issues, none of which are directly related to thrombophlebitis.
The nurse is assessing a client who has just been admitted with a diagnosis of acute pancreatitis. Which finding is most important for the LPN/LVN to report to the healthcare provider immediately?
- A. Elevated serum lipase level
- B. Severe abdominal pain
- C. Nausea and vomiting
- D. Hypotension
Correct Answer: D
Rationale: Hypotension is a critical finding that should be reported immediately in a client with acute pancreatitis as it may indicate severe complications such as hemorrhage or shock. While elevated serum lipase level, severe abdominal pain, and nausea/vomiting are common manifestations of acute pancreatitis, hypotension is a more urgent sign requiring immediate attention to prevent further deterioration. Hypotension can be a sign of significant fluid loss, hemorrhage, or sepsis, which are potentially life-threatening conditions that need prompt intervention. Elevated serum lipase levels, severe abdominal pain, and nausea/vomiting are important in the assessment of pancreatitis but do not indicate the same level of immediate danger as hypotension does.
The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?
- A. Swelling and redness in the affected leg
- B. Pain in the affected leg
- C. Warmth and tenderness in the affected leg
- D. A positive Homans' sign
Correct Answer: D
Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.
A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?
- A. A client who has a new diagnosis of adrenal insufficiency
- B. A client who has heart failure
- C. A client who is receiving treatment for diabetic ketoacidosis
- D. A client who has abdominal ascites
Correct Answer: B
Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.