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What is the best initial action for the nurse to take?
- A. Try to have the client breathe slower or
- B. Give O2 via nasal cannula
- C. Administer sodium bicarbonate
- D. Monitor the client’s fluid balance
Correct Answer: A
Rationale: The correct initial action for the nurse to take is A: Try to have the client breathe slower. This is because the client may be experiencing respiratory distress, and slowing down their breathing can help improve oxygenation. Giving O2 via nasal cannula (B) should be considered if the client's oxygen saturation is low after trying to slow down their breathing. Administering sodium bicarbonate (C) is not the appropriate initial action unless the client is experiencing severe acidosis. Monitoring the client's fluid balance (D) is important but not the best initial action in this scenario where respiratory distress is the concern.
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A client is diagnosed with metastatic adenocarcinoma of the stomach. The physician prescribes mitomycin (Mutamycin) with other chemotherapeutic agents for palliative treatment. How mitomycin does exert its cytotoxic effects?
- A. It inhibits deoxyribonucleic acid (DNA) synthesis
- B. It’s cell cycle-phase specific
- C. It inhibits ribonucleic acid (RNA) synthesis
- D. It inhibits protein synthesis
Correct Answer: A
Rationale: The correct answer is A: It inhibits deoxyribonucleic acid (DNA) synthesis. Mitomycin works by cross-linking DNA, leading to inhibition of DNA synthesis and ultimately causing cell death. This mechanism of action makes it effective against rapidly dividing cancer cells.
B: It’s cell cycle-phase specific - This is incorrect because mitomycin is not specific to a particular phase of the cell cycle.
C: It inhibits ribonucleic acid (RNA) synthesis - This is incorrect as mitomycin primarily targets DNA synthesis, not RNA synthesis.
D: It inhibits protein synthesis - This is incorrect as mitomycin's main mechanism of action is through DNA cross-linking, not protein synthesis inhibition.
The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
Correct Answer: C
Rationale: The correct next step after identifying nursing diagnoses is planning. Planning involves setting goals and creating a plan of care to address the patient's needs based on the identified nursing diagnoses. This step helps in determining interventions and outcomes for the patient. Assessment has already been completed, and diagnosis is the step where nursing diagnoses are identified. Implementation comes after planning, where the nurse carries out the planned interventions. Therefore, the logical next step in the nursing process after identifying nursing diagnoses is planning.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently.
A: Completing questions in chronological order may not address the current problem effectively.
C: Making accurate interpretations of the data comes after data collection, not as the first step.
D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.
An adult is on a clear liquid diet. Which food item can be offered/
- A. Milk
- B. Orange juice
- C. Jello
- D. Ice cream
Correct Answer: C
Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids that do not contain any solid particles, providing easily digestible nutrients. Jello meets these criteria as it is a clear, gelatin-based dessert that melts into a liquid form at room temperature.
Rationale:
1. Jello is a clear liquid that does not contain solid particles, making it suitable for a clear liquid diet.
2. Milk (A) and ice cream (D) are not considered clear liquids as they contain fats and proteins, which are not allowed on a clear liquid diet.
3. Orange juice (B) contains pulp and fibers, making it unsuitable for a clear liquid diet.
Summary:
Jello is the correct choice because it meets the criteria of being a clear liquid without solid particles. Milk, orange juice, and ice cream are not appropriate choices for a clear liquid diet due to their composition.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient’s presenting situation. In the problem-oriented approach, the nurse prioritizes the patient's immediate concerns to address them effectively. By focusing on the presenting situation first, the nurse can gather relevant data and identify key issues. This step ensures that the nurse addresses the most pressing problems promptly.
A: Completing questions in chronological order may not be necessary and could delay addressing the immediate concern.
C: Making accurate interpretations of data should come after gathering relevant information about the presenting situation.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific data.