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Which method of data collection will the nurse use to establish a patient’s database?
- A. Reviewing the current literature to determine evidence-based nursing actions
- B. Checking orders for diagnostic and laboratory tests
- C. Performing a physical examination
- D. Ordering medications
Correct Answer: C
Rationale: The correct answer is C because performing a physical examination is the method nurses use to establish a patient's database. This involves directly assessing the patient's physical condition, gathering data on their health status, and identifying any abnormalities or concerns. Reviewing literature (A) is important but not a direct method of collecting patient data. Checking orders for tests (B) is part of data collection but not the initial step. Ordering medications (D) is a treatment action, not data collection.
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Which of the ff nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
- A. Offering teaching aids with larged-sized letters
- B. Suggesting reduced visual activity such as reading or watching television
- C. Suggesting use of eye drops for comfort
- D. Suggesting use of glasses or contact lenses CARING FOR CLIENTS WITH EYE DISORDERS
Correct Answer: D
Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life.
A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging.
B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions.
C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.
A diabetic client develops sinusitis and otitis media accompanied by a fever of 100.8○0 F (38.2○0 C). What effect may this have on his need for insulin?
- A. It will have no effect.
- B. it will cause wide fluctuations in the
- C. it will decrease the need insulin. need for insulin
- D. It will increase the need for insulin.
Correct Answer: D
Rationale: The correct answer is D: It will increase the need for insulin. Infections like sinusitis and otitis media can lead to increased stress on the body, causing insulin resistance and higher blood sugar levels. This leads to an increased demand for insulin to regulate blood sugar levels effectively. Therefore, the diabetic client's need for insulin will likely increase in this scenario.
Incorrect choices:
A: It will have no effect - Incorrect because infections and fever can impact insulin requirements.
B: It will cause wide fluctuations in the need for insulin - Incorrect as infections generally lead to increased insulin needs, not fluctuations.
C: It will decrease the need for insulin - Incorrect as infections and fever typically increase insulin requirements due to increased stress on the body.
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.
A client has been diagnosed with type 1 diabetes mellitus. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?
- A. “You’ll need more insulin when you exercise or increase your food intake.”
- B. “You’ll need less insulin when you exercise or reduce your food intake.”
- C. “You’ll need less insulin when you increase your intake.”
- D. “You’ll need more insulin when you exercise or decrease your food intake.”
Correct Answer: A
Rationale: The correct answer is A: “You’ll need more insulin when you exercise or increase your food intake.” In type 1 diabetes, exercise and increased food intake can lead to increased glucose levels, requiring more insulin to maintain blood sugar control. Increasing physical activity can enhance insulin sensitivity, necessitating adjustments in insulin dosage. Choices B, C, and D are incorrect as they do not align with the physiological response in type 1 diabetes. B suggests needing less insulin when exercising, which is inaccurate as physical activity can lower blood sugar levels. C implies needing less insulin with increased food intake, which is incorrect as more food can lead to higher glucose levels. D suggests needing more insulin when decreasing food intake, which is not necessarily true as lower food intake can result in lower glucose levels.
The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The correct answer is A.
1. Change in level of consciousness is crucial in assessing neurological status.
2. Tachypnea indicates possible respiratory distress or oxygenation issues.
3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion.
4. Petechiae can be a sign of bleeding disorders or sepsis.
Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms.
Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E.
Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.