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Which action will the nurse take after the plan of care for a patient is developed?
- A. Place the original copy in the chart, so it cannot be tampered with or revised.
- B. Communicate the plan to all health care professionals involved in the patient’s care.
- C. File the plan of care in the administration office for legal examination. NursingStoreRN
- D. Send the plan of care to quality assurance for review.
Correct Answer: B
Rationale: The correct answer is B because after developing a plan of care, the nurse must communicate it to all healthcare professionals involved in the patient's care to ensure everyone is aware of the plan and can collaborate effectively. This promotes continuity of care and prevents errors.
Choice A is incorrect because the plan of care should not be placed in the chart to avoid tampering; it should be easily accessible for updates. Choice C is incorrect as filing in the administration office is unnecessary for routine care. Choice D is incorrect as sending the plan to quality assurance is not the immediate next step after developing the plan.
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The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
- A. there is no insulin available for the state of hyperglycemia
- B. the type II diabetic has no protein of fat reserves
- C. there is no sufficient insulin to prevent the breakdown of protein and fatty acid for metabolic needs
- D. there is insufficient serum glucose concentrations
Correct Answer: C
Rationale: Rationale for Choice C (Correct answer):
- In type II DM, there is some insulin present but it is insufficient to meet the body's needs.
- Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy.
- This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA).
- Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs.
Summary of other choices:
- Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient.
- Choice B is incorrect as type II diabetics do have fat and protein reserves.
- Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.
Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:
- A. Kaposi's Sarcoma
- B. Pneumonia Carnii
- C. Filterable Virus
- D. Staphylococcus bacteria
Correct Answer: B
Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.
Which of the following is an important preventive factor that the nurse should teach a client with rhinitis?
- A. Not to blow the nose
- B. Not to lift objects weighing more than 5-10 lb
- C. To consume small doses of ice chips
- D. To wash hands frequently
Correct Answer: D
Rationale: The correct answer is D: To wash hands frequently. This is important in rhinitis prevention as it helps reduce the spread of viruses and bacteria that can trigger or exacerbate symptoms. Washing hands removes potential allergens and irritants, reducing the risk of rhinitis flare-ups.
Choice A is incorrect as blowing the nose is necessary to clear mucus and alleviate symptoms. Choice B is irrelevant to rhinitis prevention. Choice C is not directly related to preventing rhinitis.
Which patient would benefit most from a capped IV catheter that is used intermittently rather than continuously?
- A. The patient with pneumonia who needs fluids and antibiotics.
- B. The patient who has had major blood loss after a motor vehicle accident.
- C. The young child who is dehydrated.
- D. The elderly patient who is receiving a diuretic for fluid overload.
Correct Answer: D
Rationale: The correct answer is D, the elderly patient receiving a diuretic for fluid overload. This patient would benefit most from a capped IV catheter used intermittently because diuretics can lead to fluctuations in fluid balance that require careful monitoring and adjustment of IV fluids. By using the catheter intermittently, healthcare providers can better control the amount of fluid administered to prevent electrolyte imbalances.
Option A is incorrect because a patient with pneumonia requiring fluids and antibiotics would likely benefit from a continuous IV to maintain stable levels of medications and hydration. Option B is incorrect as a patient with major blood loss would require continuous IV fluids to restore blood volume. Option C is incorrect as a dehydrated young child would also benefit from continuous IV fluids to rehydrate effectively.
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
- A. The patient’s room with the door closed
- B. The waiting area with the television turned off
- C. The patient’s room before administration of pain medication
- D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B
Rationale: The correct answer is B because conducting the interview in a quiet environment, such as the waiting area with the television turned off, minimizes background noise and distractions for a patient with a hearing deficit. This setting allows for better communication and ensures that the patient can hear and understand the nurse clearly.
A: Conducting the interview in the patient's room with the door closed may still have background noise from the hallway or other rooms.
C: Conducting the interview before administration of pain medication is not relevant to improving communication for a patient with a hearing deficit.
D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional noise and distractions, making it difficult for the patient to focus on the conversation.