Nokea
When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?
- A. Yes, I have. Do you have some questions about dying?
- B. Several times. Now, let's get your dressing changed.
- C. A few times. It was peaceful and there was no pain.
- D. Yes, but you're doing great. Are you concerned about dying?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy and encourages open communication. The nurse acknowledges the client's question and offers support by asking if they have any concerns. This response demonstrates active listening and shows the nurse is willing to address the client's emotional needs.
Choice B is incorrect as it dismisses the client's question and focuses solely on the task at hand, lacking empathy. Choice C is incorrect as it provides a general statement about previous experiences without directly addressing the client's inquiry. Choice D is incorrect as it deflects the question and does not actively engage with the client's emotional concerns.
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The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: C
Rationale: Rationale:
1. Heparin primarily affects the intrinsic pathway of coagulation.
2. International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy.
3. INR is more specific for monitoring heparin therapy compared to other options.
4. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not as accurate for heparin monitoring.
5. Partial Thromboplastin Time (PTT) is used to monitor heparin therapy, but INR is a more precise indicator of heparin's effect.
The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
- A. Activity tolerance as evidenced by appropriate age-level activities being performed
- B. Absence of skin breakdown as evidenced by intact skin and absence of redness
- C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
- D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr
Correct Answer: D
Rationale: The correct answer is D. In acute glomerulonephritis, the kidneys are inflamed, affecting fluid balance. Monitoring urine output of 1 to 2 ml/kg/hr is crucial to assess kidney function and prevent fluid overload or dehydration. This is the priority outcome as it directly reflects kidney function and overall fluid balance.
A: Activity tolerance is important but not the priority in acute glomerulonephritis.
B: Absence of skin breakdown is important for overall health but not directly related to the condition.
C: Nutritional status is important, but fluid balance takes precedence in managing acute glomerulonephritis.
In summary, maintaining fluid balance is crucial in managing acute glomerulonephritis as it directly reflects kidney function, while the other options are important but not the priority in this scenario.
A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?
- A. Allow the child to eat foods desired and tolerated
- B. Restrict foods brought from fast food restaurants
- C. Recommend eating the same foods as siblings eat at home
- D. Encourage a variety of large portions of food at every meal
Correct Answer: A
Rationale: Step 1: A child with Leukemia undergoing chemotherapy often experiences anorexia, nausea, and vomiting, leading to altered nutrition.
Step 2: Allowing the child to eat foods desired and tolerated promotes intake, ensuring adequate nutrition.
Step 3: Restricting foods (Choice B) can exacerbate the child's already limited intake and lead to nutritional deficiencies.
Step 4: Recommending the same foods as siblings (Choice C) may not address the specific needs of the child undergoing chemotherapy.
Step 5: Encouraging large portions of food (Choice D) may overwhelm the child and worsen their symptoms.
A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
- A. The client is experiencing increased intracranial pressure
- B. He has a good prognosis for recovery
- C. This client is conscious, but is not oriented to time and place
- D. He is in a coma, and has a very poor prognosis
Correct Answer: D
Rationale: The correct answer is D because a Glasgow Coma Scale score of 3 indicates deep unconsciousness, which is classified as a coma. A GCS score of 3 signifies the lowest possible level of consciousness and is associated with a very poor prognosis due to the severity of neurological impairment. Choices A, B, and C are incorrect. Increased intracranial pressure may be present in comatose patients but is not solely indicated by a GCS score of 3. A good prognosis is unlikely with a GCS score of 3. Being unconscious with a GCS score of 3 does not equate to being conscious but disoriented as in choice C.
A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?
- A. Offer to obtain a new breakfast tray in an hour so the client can take the Zithromax
- B. Instruct the client to eat his breakfast and take the Zithromax two hours after eating
- C. Tell the client to skip that day's dose and resume taking the Zithromax the next day
- D. Provide a PRN dose of an antacid to take with the Zithromax right after breakfast
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to eat his breakfast and take the Zithromax two hours after eating. This is the correct action because azithromycin is best absorbed when taken on an empty stomach, but if the client has already eaten, it is recommended to wait at least 2 hours after a meal before taking it. This ensures optimal absorption and effectiveness of the medication.
Choice A is incorrect because it does not address the timing issue of taking azithromycin on an empty stomach. Choice C is incorrect as skipping a dose of an antibiotic can lead to treatment failure. Choice D is incorrect as antacids can interfere with the absorption of azithromycin and should not be taken together.