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Which action by the nurse demonstrates use of evidence-based practice (EBP)?
- A. Gathering equipment for a procedure
- B. Documenting changes in a patient's status
- C. Questioning the use of daily central line dressing changes
- D. Clarifying a physician's prescription for morphine
Correct Answer: C
Rationale: Questioning the use of daily central line dressing changes demonstrates the use of evidence-based practice (EBP) by the nurse. In EBP, decisions about patient care should be informed by the best available evidence, clinical expertise, and patient preferences. By questioning the necessity of daily dressing changes for central lines, the nurse is seeking to ensure that the care provided is based on sound evidence and best practices rather than simply following routine procedures. This critical thinking and questioning approach aligns with the principles of evidence-based practice.
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The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
- A. "Alcohol is not contraindicated while taking this medication."
- B. "Good oral hygiene is needed, including brushing and flossing."
- C. "The medication dose may be self-adjusted depending on side effects."
- D. "The morning dose of the medication should be taken before a serum drug level is drawn."
Correct Answer: B
Rationale: Phenytoin (Dilantin) can cause gingival hyperplasia, a side effect manifested by overgrowth of the gums. To help prevent this side effect, patients taking phenytoin should maintain good oral hygiene practices, including regular brushing and flossing. This statement shows an understanding of the importance of oral care while on phenytoin therapy, making it the correct answer choice.
Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The nurse should wake up a client who is to undergo an EEG at midnight to ensure that the client receives optimum sleep before the procedure. Optimum sleep helps regulate the client's breathing patterns during the EEG, resulting in more accurate readings. Adequate rest is essential for brain activity monitoring to be as normal as possible. Waking the client at midnight allows for enough time for the client to fall back asleep before the EEG is conducted, ensuring the best possible conditions for the procedure.
The nurse evaluates that furosemide IV is effective in treating pulmonary edema if which of the following patient signs or symptoms is resolved?
- A. Pedal edema
- B. Pink, frothy sputum
- C. Jugular vein distention
- D. Bradycardia
Correct Answer: B
Rationale: Furosemide IV is a diuretic medication commonly used to treat conditions such as pulmonary edema. In the case of pulmonary edema, the excess fluid accumulates in the lungs, leading to symptoms such as difficulty breathing, wheezing, and the production of pink, frothy sputum. The presence of pink, frothy sputum is a classic sign of pulmonary edema and indicates the presence of fluid in the airways. Therefore, the nurse would evaluate the effectiveness of furosemide IV treatment by monitoring the resolution of this specific symptom, as it indicates improvement in the underlying condition of pulmonary edema.
A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:
- A. prefers to take insulin orally.
- B. has type 1diabetes.
- C. has type 2 diabetes.
- D. is pregnant and has type 2 diabet
Correct Answer: C
Rationale: Oral antidiabetic agents are medications designed specifically for the management of type 2 diabetes mellitus. They work by improving insulin sensitivity, increasing insulin production, or reducing glucose production in the liver. Type 1 diabetes mellitus is characterized by an absolute deficiency of insulin production, requiring lifelong insulin therapy. Therefore, oral antidiabetic agents are not effective for individuals with type 1 diabetes like the client in this scenario.
The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. How should the nurse interpret this finding?
- A. Normal finding
- B. Finding requiring a referral
- C. Abnormal finding
- D. Normal finding, but requires rechecking in 1 month
Correct Answer: A
Rationale: The closure of the anterior fontanel in a 14-month-old infant is a normal finding. The anterior fontanel typically closes by around 18 months of age. The closure of the fontanel is a sign of normal growth and development as the bones of the skull fuse together. It is not a cause for concern at this age, and the nurse should document this as a normal finding.