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Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)
- A. Age
- B. Blood pressure
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: D
Rationale: The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.
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A client was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?
- A. Whole grain cereal
- B. Eggs
- C. Cottage cheese
- D. Fish
Correct Answer: A
Rationale: Diverticulosis is a condition characterized by small protrusions in the intestinal tract. To manage diverticulosis, a high-fiber diet is recommended. Foods rich in fiber help prevent constipation and reduce the risk of inflammation in the intestines. Whole grain cereals are an excellent source of fiber and can aid in maintaining bowel regularity. Eggs, cottage cheese, and fish are not high-fiber foods and may not provide the necessary dietary support for a client with diverticulosis. While protein-rich foods like eggs and fish are beneficial for overall health, they are not the primary recommendation for managing diverticulosis.
What action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?
- A. Decrease the patient's evening fluid intake.
- B. Teach the patient how to use the Cred method.
- C. Suggest the use of adult incontinence briefs for nighttime only.
- D. Assist the patient to the commode every 2 hours during the day.
Correct Answer: B
Rationale: For a 40-year-old patient with multiple sclerosis experiencing urinary retention due to a flaccid bladder, teaching the Cred method is the appropriate action. The Cred method involves applying manual pressure over the bladder to aid in bladder emptying. Decreasing fluid intake is not the correct approach as it will not address the underlying issue of bladder emptying and may lead to dehydration and urinary tract infections. Using adult incontinence briefs only addresses the symptom of incontinence without addressing the bladder emptying problem. Assisting the patient to the commode every 2 hours does not actively address the issue of improving bladder emptying as effectively as teaching the Cred method.
A nurse is caring for a patient with peripheral vascular disease (PVD). The patient
complains of burning and tingling of the hands and feet and cannot tolerate touch of any
kind. Which of the following is the most likely explanation for these symptoms?
- A. Inadequate tissue perfusion leading to nerve damage.
- B. Fluid overload leading to compression of nerve tissue.
- C. Sensation distortion due to psychiatric disturbance.
- D. Inflammation of the skin on the hands and feet.
Correct Answer: A
Rationale: Patients with the peripheral vascular disease often sustain nerve damage as a result of
inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the
extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest
pain often is exacerbated by poor cardiac output. The condition is often partially or fully
relieved by placing the extremity in a dependent position, so that perfusion is enhanced by
the effects of gravity.
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment finding should the nurse immediately report to the health care provider?
- A. Patient is claustrophobic.
- B. Patient is allergic to shellfish.
- C. Patient recently used a bronchodilator inhaler.
- D. Patient is not able to remove a wedding band.
Correct Answer: B
Rationale: The correct answer is that the patient is allergic to shellfish. This is crucial because the contrast media used in CT scans is iodine-based, and individuals with iodine allergies, such as those allergic to shellfish, are at risk of adverse reactions. It is important to identify and address this allergy to prevent potential complications. The other options do not directly impact the safety or effectiveness of the CT scan with contrast media. Claustrophobia can be managed with patient support, the recent use of a bronchodilator inhaler does not typically affect the CT procedure, and not being able to remove a wedding band is not a critical concern for the scan itself.
A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:
- A. Hypotriglyceridemia
- B. Abdominal hernia
- C. Anorexia
- D. Peritonitis
Correct Answer: A
Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.