Nokea
When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
- A. Urinary output of 30 ml in an hour
- B. Central venous pressure reading of 2 cm H20
- C. Pulse rates of 120 and 110 in a 15- minute period
- D. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
Correct Answer: A
Rationale: The correct answer is A: Urinary output of 30 ml in an hour. Adequate tissue perfusion is best indicated by a sufficient urinary output, as it demonstrates proper kidney perfusion and function. A low urinary output may suggest inadequate perfusion.
Explanation for other choices:
B: Central venous pressure reading of 2 cm H20 is not a reliable indicator of tissue perfusion to vital organs.
C: Pulse rates alone are not enough to indicate tissue perfusion as they can be influenced by various factors.
D: Blood pressure readings alone may not accurately reflect tissue perfusion, especially in the context of fluid replacement therapy.
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Which of the following are examples of common factors in a client that may influence assessment priorities?
- A. Diet and exercise program
- B. Standing in the community
- C. Ability to pay for services
- D. Developmental stage
Correct Answer: A
Rationale: The correct answer is A: Diet and exercise program. This is because a client's diet and exercise program directly impact their physical health and well-being, making it an important factor to consider when determining assessment priorities. Understanding their dietary habits and level of physical activity can help identify potential health risks or areas for improvement.
Choices B, C, and D are incorrect because they do not directly relate to the client's physical health and well-being, which are crucial factors in determining assessment priorities. Standing in the community (B) may influence social interactions but does not necessarily impact assessment priorities. Ability to pay for services (C) relates to financial considerations rather than health assessment priorities. Developmental stage (D) may be important for understanding the client's cognitive and emotional development, but it is not as directly relevant to assessment priorities as diet and exercise.
A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?
- A. Reinforce the wound dressing as needed with 4 × 4 gauze.
- B. Perform the ordered dressing change twice daily.
- C. Observe wound appearance and edges.
- D. Document wound characteristics.
Correct Answer: C
Rationale: The correct answer is C: Observe wound appearance and edges. This is the first intervention the nurse should perform because assessing the wound's appearance and edges provides crucial information about the healing process and any signs of infection. It helps in determining the next steps in the care plan. Reinforcing the dressing (A) and performing dressing changes (B) should come after assessing the wound. Documenting wound characteristics (D) is important but should also follow the initial assessment.
The nurse understands that which of the ff. is a side effect most likely to be reported by patients receiving enalapril maleate (Vasotec)?
- A. Acne
- B. Diarrhea
- C. Cough
- D. Heartburn
Correct Answer: C
Rationale: The correct answer is C: Cough. Enalapril is an ACE inhibitor, and a common side effect is a dry, persistent cough due to the accumulation of bradykinin. This is a distinctive side effect of ACE inhibitors and should be reported to the healthcare provider. Acne (A), diarrhea (B), and heartburn (D) are not commonly associated with enalapril use and are less likely side effects.
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care.
Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.
When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?
- A. Breast tenderness
- B. Increased facial hair
- C. Menstrual irregularities
- D. Hair loss
Correct Answer: C
Rationale: The correct answer is C: Menstrual irregularities. After a unilateral adrenalectomy, the remaining adrenal gland may be affected by spironolactone, leading to hormonal imbalances and menstrual irregularities. This drug is a potassium-sparing diuretic that can interfere with the production of aldosterone, affecting hormonal regulation. Breast tenderness (A) is not a common side effect of spironolactone. Increased facial hair (B) is associated with hirsutism, not typically seen with spironolactone. Hair loss (D) is more commonly associated with other medications like chemotherapy, not spironolactone.