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Which action indicates the nurse is using a PICOT question to improve care for a patient?
- A. Practices nursing based on the evidence presented in court
- B. Implements interventions based on scientific research
- C. Uses standardized care plans for all patients. NursingStoreRN
- D. Plans care based on tradition
Correct Answer: B
Rationale: The correct answer is B because using a PICOT question involves formulating a research question to guide evidence-based practice. B indicates the nurse is implementing interventions based on scientific research, aligning with the PICOT framework (Patient, Intervention, Comparison, Outcome, Timeframe). This approach ensures that care decisions are supported by the best available evidence, leading to improved patient outcomes.
Choice A is incorrect because practicing nursing based on court evidence does not align with the PICOT framework. Choice C is incorrect as using standardized care plans for all patients may not consider individual patient needs and preferences as required in a PICOT question. Choice D is incorrect as planning care based on tradition does not involve integrating current research evidence as in the PICOT approach.
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Which of the ff is the most important factor in the nursing management of a client with CFS?
- A. Teaching the client how to avoid aggravating the disease
- B. Informing the client about the drug therapy that will provide significant improvement
- C. Advising the client to alter the diet and environment
- D. Educating the client about the disease process and its limitations
Correct Answer: D
Rationale: The correct answer is D because educating the client about the disease process and its limitations is crucial in managing Chronic Fatigue Syndrome (CFS). By understanding the disease, the client can make informed decisions regarding their lifestyle, activities, and self-care. This empowers the client to manage symptoms effectively and prevent exacerbations.
Choice A is not the most important factor as simply avoiding aggravating the disease does not address the overall management of CFS.
Choice B focuses solely on drug therapy, which is only one aspect of the client's management and may not provide significant improvement for all clients with CFS.
Choice C, altering diet and environment, can be helpful but may not be the most important factor as understanding the disease process and limitations is essential for long-term management and quality of life.
Which gauge IV cannula should the nurse choose when preparing to initiate a blood transfusion?
- A. 18
- B. 24
- C. 22
- D. 28
Correct Answer: A
Rationale: The correct choice is A: 18 gauge IV cannula for blood transfusion. Larger gauge allows for faster flow rate, crucial for transfusions to prevent clotting. 24, 22, and 28 gauge cannulas are too small for adequate blood flow, leading to potential complications like hemolysis or slowed infusion.
Of the following information collected during a nursing assessment, which are subjective data?
- A. vomiting, pulse 96
- B. respirations 22, blood pressure 130/80
- C. nausea, abdominal pain
- D. pale skin, thick toenails
Correct Answer: C
Rationale: Subjective data are information reported by the patient that cannot be measured or observed directly. In this case, nausea and abdominal pain are symptoms that can only be described by the patient, making them subjective data. Vomiting, pulse rate, respirations, blood pressure, pale skin, and thick toenails are all objective data, as they can be measured or observed directly by the healthcare provider. Therefore, choice C is the correct answer as it represents subjective data.
Decreasing level of consciousness is a symptom of which of the following physiological phenomena?
- A. Increased ICP
- B. Parasympathetic response
- C. Sympathetic response
- D. Increased cerebral blood flow
Correct Answer: A
Rationale: The correct answer is A: Increased ICP. Decreasing level of consciousness is a classic sign of increased intracranial pressure (ICP) due to the compression of the brain. As ICP rises, it impairs cerebral perfusion leading to altered mental status. Parasympathetic response (B) and sympathetic response (C) are related to autonomic nervous system functions, not consciousness. Increased cerebral blood flow (D) might lead to conditions like hyperemia but does not directly cause a decreased level of consciousness.
An adult is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized. He is bleeding profusely from a large gash on his right thigh. What is the first action the nurse should take?
- A. Stop the bleeding
- B. Take his vital signs
- C. Check his airway
- D. Find out what happened from eyewitnesses NEUROLOGIC DISORDERS
Correct Answer: C
Rationale: The correct answer is C: Check his airway. Ensuring a patent airway is the priority in trauma care to maintain oxygenation and ventilation. With the patient unconscious and bleeding profusely, airway obstruction or compromise is a critical concern. By checking the airway first, the nurse can quickly assess and address any immediate threats to the patient's breathing. Stopping the bleeding (choice A) can be addressed once the airway is secured. Taking vital signs (choice B) and finding out what happened from eyewitnesses (choice D) can be important but are secondary to ensuring the patient's airway is clear and unobstructed.