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What is the first action the nurse should take?
- A. Start an IV lines for fluids
- B. Get an ECG
- C. Place a Foley catheter
- D. Check for neurologic status
Correct Answer: D
Rationale: The correct answer is D: Check for neurologic status. This is the first action because assessing the patient's neurologic status helps identify any immediate threats to their health and guides further interventions. It is crucial to ensure the patient's safety and prioritize interventions based on their neurologic status. Starting an IV for fluids (A), getting an ECG (B), and placing a Foley catheter (C) are important interventions but should come after assessing the patient's neurologic status to address any urgent issues first.
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One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
- A. Massage reddened areas with lotion or oils
- B. Use special water mattress
- C. Turn frequently every 2 hours
- D. Keep skin clean and dry
Correct Answer: C
Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage.
A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin.
B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers.
D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.
A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
- A. Risk for impaired physical mobility due to surgery
- B. Ineffective denial related to poor coping mechanisms
- C. Disturbed body image related to the incision scar
- D. Risk of injury related to surgical outcomes
Correct Answer: C
Rationale: The correct answer is C, Disturbed body image related to the incision scar. This is the most appropriate nursing diagnosis as the client's concern about wearing a scarf around his neck post-surgery indicates a potential disturbance in body image. This diagnosis addresses the client's emotional response to physical changes, which is common in surgical patients.
Choice A is incorrect because impaired physical mobility is not directly related to the client's worry about wearing a scarf. Choice B is incorrect as ineffective denial does not directly address the client's specific concern about body image. Choice D is also incorrect as the risk of injury is not the primary issue in this scenario; it is more about the client's perception of their appearance post-surgery.
In summary, the client's worry about wearing a scarf post-surgery indicates a disturbance in body image, making choice C the most appropriate nursing diagnosis.
A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? “Evaluative measures are multiple-page documents used to evaluate nurse
- A. performance.” NursingStoreRN “Evaluative measures include assessment data used to determine whether patients
- B. have met their expected outcomes and goals.” “Evaluative measures are used by quality assurance nurses to determine the progress
- C. a nurse is making from novice to expert nurse.”
- D. “Evaluative measures are objective views for completion of nursing interventions.”
Correct Answer: B
Rationale: The correct answer is B because evaluative measures in nursing refer to the assessment data used to determine if patients have achieved their expected outcomes and goals. This is crucial in evaluating the effectiveness of the care provided.
Choice A is incorrect because it defines evaluative measures as multiple-page documents, which is not accurate. Choice C is incorrect as it focuses on the progression of a nurse's skill level rather than patient outcomes. Choice D is incorrect as it defines evaluative measures as objective views of completing nursing interventions, which is too narrow of a definition.
Which of the following dietary interventions prevents the precipitation of calcium renal stones?
- A. High fiber diet
- B. Increased protein intake
- C. High fluid intake
- D. Intake of zinc
Correct Answer: C
Rationale: The correct answer is C: High fluid intake. Adequate hydration helps prevent calcium from becoming concentrated in the urine, reducing the risk of calcium stone formation. Increased fiber intake (choice A) may help prevent other types of stones but not specifically calcium stones. Increased protein intake (choice B) can actually increase calcium excretion, potentially increasing the risk of calcium stone formation. Zinc intake (choice D) does not directly impact calcium stone formation. In summary, high fluid intake is crucial for preventing the precipitation of calcium renal stones due to its role in diluting urine and preventing calcium concentration.
The physician prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?
- A. “Be sure to take glipizide 30 minutes before meals.”
- B. “Glipizide may cause a low serum sodium level, so make sure you have your sodium level checked monthly.”
- C. “You won’t need to check you blood glucose level after you start taking glipizide.”
- D. “Take glipizide after a metal to prevent heartburn.”
Correct Answer: A
Rationale: The correct answer is A: “Be sure to take glipizide 30 minutes before meals.” This instruction is correct because glipizide is an oral antidiabetic agent that works best when taken before meals to help control blood glucose levels. Taking it before meals allows the medication to coincide with the body's natural insulin response to food intake, thereby improving its effectiveness.
Choice B is incorrect because glipizide does not typically cause low serum sodium levels, so there is no need for monthly sodium level checks. Choice C is incorrect because it is essential for the client to continue monitoring their blood glucose levels even after starting glipizide to ensure the medication is working effectively. Choice D is incorrect because taking glipizide after a meal will not optimize its effectiveness in controlling blood glucose levels.