Nokea
Which food choice contains the highest kilocalorie?
- A. Apple
- B. Chicken
- C. Bacon
- D. Bread
Correct Answer: C
Rationale: The correct answer is C: Bacon. Bacon contains the highest kilocalorie among the given choices due to its high fat content. Fat provides 9 kilocalories per gram, while carbohydrates (like in bread and apple) provide 4 kilocalories per gram and protein (like in chicken) provides 4 kilocalories per gram. Bacon, being high in fat, has more kilocalories compared to the other choices.
Summary:
A: Apple - Low in fat, primarily consists of carbohydrates, hence lower in kilocalories.
B: Chicken - Contains protein, lower in kilocalories compared to fat, hence not the highest kilocalorie choice.
D: Bread - Mainly consists of carbohydrates, lower in kilocalories compared to fat, making it not the highest kilocalorie choice.
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Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:
- A. cover wound with moist sterile dressing
- B. find out how this happened
- C. place sterile dry gauze on the wound
- D. pour sterile water into the wound
Correct Answer: A
Rationale: Correct Answer: A: Cover wound with moist sterile dressing
Rationale:
1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing.
2. Moist dressing prevents the wound from drying out and minimizes the risk of infection.
3. The moist environment supports healing by promoting cell growth and preventing tissue damage.
4. It protects the exposed bowel from further injury and contamination.
Summary:
B: Finding out how this happened is important but not an immediate priority for patient care.
C: Placing sterile dry gauze can lead to the wound drying out and hinder healing.
D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.
Which of the following signs indicates to the nurse that digoxin (Lanoxin) has been effective for a patient?
- A. Urine output decreases
- B. Heart rate higher than 95
- C. Urine output increases
- D. Heart rate lower than 50
Correct Answer: C
Rationale: The correct answer is C: Urine output increases. This indicates digoxin's effectiveness as it improves cardiac output by enhancing contraction strength. Increased urine output signifies improved kidney perfusion due to enhanced cardiac function. Option A is incorrect as decreased urine output indicates poor kidney perfusion. Option B is incorrect as digoxin aims to regulate heart rate, not necessarily make it higher than 95. Option D is incorrect as a heart rate lower than 50 could indicate digoxin toxicity.
The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
- A. Begin a program of aggressive, strict mouth care
- B. Avoid traumatic injuries and exposure to any infection
- C. increase oral fluid intake to a minimum of 3000 ml daily
- D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B
Rationale: The correct answer is B - Avoid traumatic injuries and exposure to any infection. For a client with pancytopenia caused by chemotherapy, their immune system is compromised, making them more susceptible to infections and bleeding. By avoiding traumatic injuries and exposure to infections, the client can reduce the risk of complications. Option A is incorrect because aggressive mouth care may further damage the already compromised oral mucosa. Option C is incorrect because excessive fluid intake may not be necessary and could worsen electrolyte imbalances. Option D is incorrect because muscle cramps and tingling sensations are not directly related to the main concern of infection and bleeding in pancytopenia.
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (sub-arachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
- A. To prevent confusion
- B. To prevent cerebrospinal fluid (CSF) leakage
- C. To prevent seizures
- D. To prevent cardiac arrhythmias
Correct Answer: B
Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage.
1. Positioning is crucial to prevent CSF leakage as the spinal block is administered into the sub-arachnoid space where CSF is present.
2. Incorrect Answers:
A: Positioning is not related to preventing confusion in this context.
C: Seizures are not typically associated with spinal block anesthesia.
D: Cardiac arrhythmias are not directly impacted by the client's positioning for a spinal block.
A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
- A. Assigning clinical cues
- B. Defining characteristics
- C. Diagnostic reasoning NursingStoreRN
- D. Diagnostic labeling
Correct Answer: C
Rationale: The correct answer is C: Diagnostic reasoning. The nurse is utilizing assessment data to analyze and interpret the information to develop a nursing diagnosis. This involves critical thinking skills to make conclusions and create a plan of care.
A: Assigning clinical cues - This choice is incorrect as it refers to identifying objective and subjective data during assessment, not the process of analyzing and synthesizing data to form a diagnosis.
B: Defining characteristics - This choice is incorrect as it typically refers to the specific manifestations or symptoms associated with a particular nursing diagnosis, not the process of diagnosing itself.
D: Diagnostic labeling - This choice is incorrect as it refers to the final step in the nursing diagnosis process where the nurse assigns a label to the identified problem, not the overall process of diagnostic reasoning.