Nokea
Which client should the nurse assess frequently because of the risk for overflow incontinence?
- A. A client who is bedfast, with increased serum BUN and creatinine levels
- B. A client with hematuria and decreasing hemoglobin and hematocrit levels
- C. A client who has a history of frequent urinary tract infections
- D. A client who is confused and frequently forgets to go to the bathroom
Correct Answer: A
Rationale: The correct answer is A. Bedfast clients with increased serum BUN and creatinine levels are at high risk for overflow incontinence. This occurs due to decreased bladder function and reduced ability to sense bladder fullness, leading to the bladder overfilling and leaking urine. Choice B describes symptoms related to possible urinary tract infections or renal issues, but these do not directly indicate overflow incontinence. Choice C, a history of frequent urinary tract infections, may suggest other urinary issues but not specifically overflow incontinence. Choice D, a confused client who forgets to go to the bathroom, is more indicative of functional incontinence rather than overflow incontinence.
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What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?
- A. Encourage family members to cook meals outdoors and bring the cooked food inside
- B. Advise the client to replace cooked foods with a variety of different nutritional supplements
- C. Assess the client's mucus membranes and report the findings to the healthcare provider
- D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
Correct Answer: A
Rationale: The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.
An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client used to run a year ago, his spouse states that the client no longer runs but sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today?
- A. Assist the client in identifying goals for the day
- B. Encourage the client to participate in a team sport for one hour
- C. Schedule the client for a group session that focuses on self-esteem
- D. Help the client develop a list of daily affirmations
Correct Answer: A
Rationale: Assisting the client in identifying goals for the day is the most important aspect of the plan of care for a client with severe depression. Setting achievable daily goals helps engage the client in activities and promotes a sense of accomplishment, which can contribute to gradual improvement in their condition. Encouraging participation in team sports may be overwhelming for a client with severe depression as it requires a significant level of energy and motivation that the client may not possess at this time. Group sessions focusing on self-esteem and daily affirmations are beneficial interventions, but they may not have an immediate impact compared to setting achievable daily goals that can provide a sense of purpose and achievement for the client.
Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?
- A. Neutrophils
- B. Lymphocytes
- C. Eosinophils
- D. Monocytes
Correct Answer: C
Rationale: Eosinophils are the correct answer. Eosinophils are specialized white blood cells that play a crucial role in allergic responses and combating parasitic infections. They release substances to destroy parasites and modulate allergic reactions. Neutrophils (Choice A) are mainly involved in fighting bacterial infections. Lymphocytes (Choice B) play a key role in the immune response, including antibody production, but are not primarily responsible for combating parasites or allergic responses. Monocytes (Choice D) are involved in immune defense, differentiating into macrophages or dendritic cells, but they are not mainly associated with allergic responses or parasitic worm destruction.
Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?
- A. Transfuse Type A negative blood until type AB negative is available.
- B. Recheck the client's hemoglobin, blood type, and Rh factor.
- C. Administer normal saline solution until type AB negative is available.
- D. Obtain additional consent for the administration of type A negative blood.
Correct Answer: A
Rationale: In emergency situations where AB negative blood is unavailable, type A negative blood can be transfused to a patient with AB negative blood type. Type A negative blood is compatible with AB negative blood, making it a suitable option until the correct blood type becomes available. Transfusion of Type A negative blood is crucial to address the severe anemia promptly. Rechecking the client's hemoglobin, blood type, and Rh factor (Choice B) may delay necessary treatment. Administering normal saline solution (Choice C) is not a substitute for blood transfusion in cases of severe anemia. Obtaining additional consent for the administration of type A negative blood (Choice D) is unnecessary as the situation is emergent and the blood type is compatible.
The urinary drainage of a client with continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement?
- A. Increase the irrigation rate
- B. Lower the head of the bed
- C. Milk the catheter tubing
- D. Evaluate for fluid overload
Correct Answer: A
Rationale: Increasing the irrigation rate can help clear any blood clots and reduce the redness in the urinary drainage. This intervention aims to improve the flushing of the bladder and potentially resolve the issue. Lowering the head of the bed would not directly address the red urinary drainage. Milking the catheter tubing is not recommended as it can cause trauma to the catheter or bladder, leading to further complications. While evaluating for fluid overload is an important nursing consideration, it does not directly address the immediate concern of redness in the urinary drainage, which requires a focused intervention to clear any blockages or clots in the system.