Nokea
What intervention would be the most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing every day at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The most important intervention for a client with a left nephrectomy is to assess the intravenous fluids for rate and volume. After nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Changing the surgical dressing daily, monitoring medication levels, and tracking meal intake are also important aspects of care but not as critical as ensuring adequate intravenous fluid management post-surgery.
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The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?
- A. Ensure the scene is safe, assess responsiveness, call for help, begin chest compressions, give two rescue breaths
- B. Give two rescue breaths
- C. Look, listen, and feel for breathing
- D. Begin chest compressions
Correct Answer: A
Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.
Which intervention should the nurse implement for the client who has an ileal conduit?
- A. Pouch the stoma with a one-inch margin around the stoma
- B. Refer the client to the United Ostomy Association for discharge teaching
- C. Report to the healthcare provider any decrease in urinary output
- D. Monitor the stoma for signs and symptoms of infection every shift
Correct Answer: C
Rationale: The correct intervention for a client with an ileal conduit is to report to the healthcare provider any decrease in urinary output. A decrease in urinary output can be indicative of a blockage or other complication, necessitating immediate attention. Choice A is incorrect because pouching the stoma with a margin around it is not directly related to managing complications. Choice B is incorrect as referring the client to an ostomy association may be beneficial for education but is not the immediate action needed for decreased urinary output. Choice D is incorrect because monitoring for infection, although important, is not the priority when dealing with a potential complication like decreased urinary output.
Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task of 'Listening and responding to soldiers' suggestions and complaints'?
- A. Accountability
- B. Personal/professional development
- C. Individual training
- D. Military appearance/physical condition
Correct Answer: A
Rationale: The correct answer is A: Accountability. Accountability in personnel management involves being responsible for one's actions and decisions. Part of being accountable includes listening to and addressing soldiers' suggestions and complaints. This helps in fostering a positive work environment and improving communication within the team. Choices B, C, and D are incorrect because while personal/professional development, individual training, and military appearance/physical condition are important aspects of personnel management, they do not directly relate to the specific task of listening and responding to soldiers' suggestions and complaints.
What intervention would be most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing daily at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The correct answer is A: Assess the intravenous fluids for rate and volume. After a nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Choice B is incorrect because changing the surgical dressing daily is important but not the most critical intervention. Choice C is incorrect as monitoring medication levels daily may be necessary but is not the priority after a nephrectomy. Choice D is irrelevant to the immediate postoperative care needed after a nephrectomy.
The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in a minute
- B. The client diagnosed with coronary artery disease who wants to ambulate
- C. The client diagnosed with mitral valve prolapse with an audible S3
- D. The client diagnosed with pericarditis who is in normal sinus rhythm
Correct Answer: C
Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure and requires immediate assessment. Choice A is not as urgent as an audible S3 in mitral valve prolapse. Choice B, a client with coronary artery disease wanting to ambulate, does not present an immediate concern compared to a potential heart failure indicated by an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable and does not require immediate attention when compared to a potential heart failure situation signified by an audible S3 in mitral valve prolapse.