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When caring for an anxious patient with dyspnea, which of the ff. nursing actions is most helpful to include in the plan of care to relieve anxiety?
- A. Increasing activity levels
- B. Pulling the privacy curtain
- C. Staying at patient’s bedside
- D. Closing the patient’s door
Correct Answer: C
Rationale: The correct answer is C: Staying at patient's bedside. This is the most helpful nursing action because it provides reassurance and support to the anxious patient experiencing dyspnea. By staying at the bedside, the nurse can monitor the patient closely, provide immediate assistance if needed, and offer a calming presence.
Explanation of why other choices are incorrect:
A: Increasing activity levels may worsen the dyspnea and anxiety of the patient.
B: Pulling the privacy curtain does not directly address the patient's anxiety or dyspnea.
D: Closing the patient's door may make the patient feel isolated and increase anxiety.
In summary, staying at the patient's bedside is the most effective nursing action as it addresses both the physical and emotional needs of the anxious patient with dyspnea.
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Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
- A. fluid and electrolyte imbalances
- B. hepatotoxicity
- C. infection
- D. respiratory complications
Correct Answer: A
Rationale: The correct answer is A because post-kidney transplant patients are at high risk for fluid and electrolyte imbalances due to the impact of the surgery on renal function. The nurse should assess for signs of fluid overload or depletion and monitor electrolyte levels closely. Choice B, hepatotoxicity, is less immediate and not directly related to kidney transplant. Choice C, infection, is important but not the immediate priority. Choice D, respiratory complications, are also significant but not the most immediate concern post-kidney transplant.
Which of the ff. actions would the nurse include in the plan of care to reduce the symptoms of the patient who has vertigo?
- A. Avoid noises
- B. Encourage fluid intake
- C. Avoid sudden movements
- D. Administer analgesics
Correct Answer: C
Rationale: The correct answer is C: Avoid sudden movements. Vertigo is a type of dizziness where a person feels like they're spinning or the world around them is spinning. Sudden movements can worsen vertigo symptoms. By avoiding sudden movements, the nurse can help reduce the patient's vertigo symptoms.
Avoiding noises (A) may help with other conditions like migraines, but it is not specifically helpful for vertigo. Encouraging fluid intake (B) is important for overall health but does not directly address vertigo symptoms. Administering analgesics (D) may help with pain but will not address the underlying cause of vertigo.
Therefore, choosing option C is the most appropriate action to include in the plan of care for reducing vertigo symptoms.
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. Problem statement
- B. Defining characteristics
- C. Etiology of the problem
- D. Outcomes criteria
Correct Answer: C
Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem.
Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.
A nurse is providing education to a client with newly diagnosed hypertension about the importance of adhering to prescribed medications. Which phase of the nursing process does this activity represent?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: C
Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.
Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis
- B. It minimizes the risk of circulatory overload
- C. It minimizes the risk of pulmonary
- D. It minimizes the risk of localized edema embolism
Correct Answer: B
Rationale: The correct answer is B: It minimizes the risk of circulatory overload. When a venous access device dislodges during a transfusion, there is a risk of the infusion going into the surrounding tissues instead of the vein, leading to circulatory overload. This can result in fluid overload and potentially lead to serious complications such as heart failure. Monitoring the device ensures that the medication is delivered safely and effectively into the bloodstream.
Choices A, C, and D are incorrect:
A: Monitoring the device does not directly minimize the risk of phlebitis, which is inflammation of the vein.
C: Monitoring the device does not directly minimize the risk of pulmonary complications, which are not typically associated with a dislodged venous access device.
D: Monitoring the device does not directly minimize the risk of localized edema embolism, which is a blockage caused by a blood clot, air bubble, or other material in a blood vessel.