Nokea
When a student encounters problems while trying to reach a goal and then claims that she is a failure is an example of-
- A. Realistic thinking
- B. The best way to reach a goal
- C. Distortion of thinking
- D. Adjustment of thinking process
Correct Answer: C
Rationale: Failure claim is distortion , not realistic, best, or adjustment. Nurse leaders like reframing setbacks counter this, contrasting with negativity. In healthcare, resilience aids progress, aligning leadership with positive mindset.
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The nurse is assessing a client with suspected hyperglycemia. Which finding supports this diagnosis?
- A. Polyuria
- B. Sweating
- C. Muscle cramps
- D. Shakiness
Correct Answer: A
Rationale: In suspected hyperglycemia, polyuria supports it, not sweating, cramps, or shakiness (hypoglycemia signs). High glucose spills into urine frequent urination signals control issues, unlike adrenergic responses. Leadership notes this imagine thirst; it guides insulin, aligning with diabetes care effectively.
The nurse is preparing to administer a dose of amoxicillin to a client with a urinary tract infection. Which laboratory value should the nurse review prior to administration?
- A. Serum creatinine
- B. White blood cell count
- C. Blood glucose
- D. Potassium
Correct Answer: A
Rationale: Before amoxicillin for a UTI, review serum creatinine, not WBC, glucose, or potassium. Penicillins are renally cleared creatinine flags kidney function, guiding dosing. Others track infection or unrelated issues. Leadership checks this imagine oliguria; it prevents toxicity, aligning with antibiotic care effectively.
A nurse is caring for a client who is postoperative following abdominal surgery and has a nasogastric (NG) tube to low intermittent suction. Which of the following findings should the nurse report to the provider?
- A. Absence of bowel sounds
- B. NG tube output of 200 mL in 4 hours
- C. Abdominal distension
- D. Gastric residual of 50 mL
Correct Answer: A
Rationale: Post-abdominal surgery, an NG tube to low intermittent suction decompresses the stomach, aiding recovery. Absence of bowel sounds indicates ileus paralysis of intestinal motility a potential complication like obstruction or peritonitis, requiring provider notification for imaging or intervention. NG output of 200 mL in 4 hours (50 mL/hr) is expected, removing fluid or gas, while distension may occur but isn't urgent unless worsening with other signs. Gastric residual of 50 mL is minimal, not concerning with suction. Absent bowel sounds signal a critical deviation, demanding prompt reporting to prevent escalation, reflecting the nurse's role in vigilant postoperative monitoring.
The old client had to walk along the hall to reach the examination room. During assessment the nurse hears an S4. Which is the best intervention at this moment?
- A. Practice an EKG
- B. Administer nitroglycerin sublingual
- C. Allow rest recumbent for 30 minutes
- D. Call MD immediately
Correct Answer: C
Rationale: An S4 in an elder post-walk suggests diastolic stiffness the nurse allows 30 minutes recumbent rest, not EKG, nitroglycerin, or calling. S4 often reflects aging or exertion, not acute ischemia; rest distinguishes transient from persistent findings. EKG or nitroglycerin assumes angina, and calling escalates prematurely. Leadership opts for this imagine a tired patient; rest clarifies if S4 persists, guiding next steps. This reflects nursing's prudent assessment, ensuring accurate cardiac care in geriatrics effectively.
The nurse is caring for a client with an indwelling urinary catheter. Which intervention is the priority to prevent infection?
- A. Empty the drainage bag every 8 hours
- B. Secure the catheter to the leg
- C. Clean the insertion site daily
- D. Encourage fluid intake
Correct Answer: C
Rationale: With an indwelling catheter, clean the site daily is priority, not emptying, securing, or fluids. Cleaning cuts infection others help but germs at entry matter most. Leadership ensures this imagine cloudy urine; it prevents UTI, aligning with catheter care effectively.