Nokea
What is the primary purpose of using measurable client outcomes during the nursing process?
- A. To diagnose client conditions accurately.
- B. To evaluate the effectiveness of nursing interventions.
- C. To prioritize nursing diagnoses effectively.
- D. To guide documentation in the client’s health record.
Correct Answer: B
Rationale: The primary purpose of using measurable client outcomes during the nursing process is to evaluate the effectiveness of nursing interventions. This is crucial in determining whether the care provided has led to the desired outcomes for the client's health. By measuring outcomes, nurses can assess if the interventions are successful, make any necessary adjustments to the care plan, and ensure optimal patient outcomes.
Choice A is incorrect because diagnosing client conditions accurately is not the primary purpose of using measurable client outcomes; it is more related to the initial assessment phase.
Choice C is incorrect because prioritizing nursing diagnoses effectively is an important aspect of the nursing process, but it is not the primary purpose of using measurable client outcomes.
Choice D is incorrect because while documentation in the client's health record is important, it is not the primary purpose of using measurable client outcomes.
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The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:
- A. Renal calculi
- B. Delayed ejaculation
- C. Hematuria
- D. Impotence
Correct Answer: C
Rationale: The correct answer is C: Hematuria. Bacillus Calmette-Guerin (BCG) is a type of immunotherapy used to treat bladder cancer by stimulating the immune system to attack cancer cells. One common side effect of BCG instillations is hematuria, which is the presence of blood in the urine. This occurs because BCG irritates the bladder lining, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware and can report any excessive bleeding to their healthcare provider promptly.
Other choices are incorrect:
A: Renal calculi - BCG therapy is not known to cause renal calculi.
B: Delayed ejaculation - BCG therapy is not associated with delayed ejaculation.
D: Impotence - BCG therapy is not linked to impotence.
Which of the following questions or statements would be an appropriate termination of the health history interview?
- A. “Well, I can’t think of anything else to ask you right now.”
- B. “Can you think of anything else you would like to tell me?”
- C. “I wish you could have remembered more about your illness.”
- D. “Perhaps we can talk again sometime. Goodbye.”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.
The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?
- A. Teaches proper handwashing technique
- B. Properly cleans the patient’s toilet
- C. Transports urine specimen to the lab
- D. Informs the oncoming nurse during hand-off
Correct Answer: A
Rationale: The correct answer is A: Teaches proper handwashing technique. This is the most appropriate intervention because proper handwashing can help prevent the spread of infection, including urinary infections. Teaching the patient about handwashing empowers them to take control of their own hygiene, reducing the risk of infection.
Summary of why other choices are incorrect:
B: Properly cleans the patient's toilet - While important for maintaining cleanliness, this does not directly address the patient's risk for a urinary infection.
C: Transports urine specimen to the lab - This is not a direct care intervention for preventing urinary infections.
D: Informs the oncoming nurse during hand-off - Hand-off communication is important for continuity of care but does not directly address the patient's risk for a urinary infection.
The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 70 and 120mg/dl
- C. Between 120 and 180mg/dl
- D. Over 180mg/dl A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET P
Correct Answer: A
Rationale: The correct answer is A, below 70mg/dl, for a hypoglycemic client. Hypoglycemia is defined as low blood glucose levels, typically below 70mg/dl. Symptoms of hypoglycemia include confusion, sweating, shakiness, and palpitations. Treating hypoglycemia involves providing the client with a fast-acting source of glucose to raise their blood sugar levels quickly. Choices B, C, and D are incorrect as they indicate normal or elevated blood glucose levels, which are not characteristic of hypoglycemia. It is crucial for the nurse to recognize and promptly address hypoglycemia to prevent potential complications.
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: C
Rationale: The correct answer is C: Maintaining the integrity of the urinary system. This is crucial in preoperative preparation for a client with malignant tumors to prevent complications such as urinary obstruction or infection. Assessing symptoms of peritonitis (B) is important but not as critical as ensuring urinary system integrity. Insertion of an ostomy pouch (A) and nasogastric tube diversion procedure (D) may be necessary interventions for some cases, but they are not as essential as ensuring the urinary system's integrity to prevent serious complications.