Nokea
Where was the mistake made in the nursing process with this patient?
- A. Planning
- B. Diagnosis
- C. Evaluation
- D. Assessment
Correct Answer: B
Rationale: The initial diagnosis of ineffective self-health management overlooked the financial barrier, which is a root cause rather than lack of knowledge.
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Joan has osteoporosis. She has an increased risk for
- A. Infection in the bone.
- B. Peripheral blood clot formation.
- C. Fracture formation.
- D. Painful joint inflammation.
Correct Answer: C
Rationale: Osteoporosis weakens bones, increasing the risk of fractures.
A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?
- A. Clamp the tube when the client is ambulating.
- B. Keep the collection device below the level of the client's chest.
- C. Carefully coil the tubes to prevent kinking.
- D. Position the client flat to avoid leaks in the tubing.
Correct Answer: B
Rationale: The correct answer is B: Keep the collection device below the level of the client's chest. This is important to ensure proper drainage and prevent backflow or air from entering the pleural space. Placing the collection device below the chest allows gravity to assist in drainage. Clamping the tube while ambulating (choice A) can lead to increased pressure in the chest, risking complications. Coiling the tubes (choice C) may cause kinks, obstructing drainage. Positioning the client flat (choice D) can lead to leaks in the tubing due to elevated pressure.
Tom complains of hunger and lack of energy midmorning. What suggestion would be most helpful?
- A. As a midmorning snack drink a glass of apple juice and eat a pear
- B. Drink only coffee with sugar for breakfast
- C. Eat a sweet roll midmorning
- D. Drink a glass of orange juice and eat three pieces of toast for breakfast
Correct Answer: A
Rationale: A balanced snack like apple juice and a pear provides quick energy and nutrients without excessive calories.
A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: The correct answer is A: Respiratory acidosis. Shallow respirations at 9/min indicate hypoventilation, leading to retention of CO2 and respiratory acidosis. This is because inadequate removal of CO2 results in an increase in carbonic acid concentration, leading to a decrease in blood pH. Respiratory alkalosis (B) is unlikely with shallow respirations. Metabolic acidosis (C) results from nonrespiratory factors. Metabolic alkalosis (D) is not related to respiratory rate.
The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
- A. Glucose level of 120 mg/dl.
- B. History of myocardial infarction.
- C. Long term steroid usage.
- D. Diet high in carbohydrates.
Correct Answer: C
Rationale: Steroids impair wound healing by affecting collagen formation and immune response.