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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: Performing a physical examination. This method allows the nurse to collect objective data directly from the patient, which is crucial in establishing a comprehensive patient database. By assessing the patient's physical condition, the nurse can gather vital information such as vital signs, overall health status, and potential areas of concern. Reviewing literature (A) and checking orders for tests (B) may provide additional insights but are not direct data collection methods. Ordering medications (D) is a treatment intervention, not a data collection method.
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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.
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.
Within 20 minutes of the start of transfusion, the client develops a sudden fever. What is the nurse’s first action?
- A. Force fluids
- B. Increase the flow rate of IV fluids
- C. Continue to monitor the vitals signs
- D. Stop the transfusion
Correct Answer: D
Rationale: The correct answer is D: Stop the transfusion. This is the first action the nurse should take because the sudden fever could indicate a transfusion reaction. Stopping the transfusion is crucial to prevent further complications. Continuing to monitor vital signs (choice C) may delay necessary intervention. Forcing fluids (choice A) could worsen the situation if it is a reaction to the transfusion. Increasing the flow rate of IV fluids (choice B) is not indicated as the priority is to stop the transfusion to prevent a potential adverse event.
After surgery the nurse notes that the patient’s urine is dark amber and concentrated. Which of the following does the nurse understand may be the reason for this?
- A. The sympathetic nervous system saves fluid in response to stress of surgery.
- B. The sympathetic nervous system diereses fluid in response to stress of surgery.
- C. The parasympathetic nervous system saves fluid in response to stress of surgery.
- D. The parasympathetic nervous system diereses fluid in response to stress of surgery.
Correct Answer: A
Rationale: The correct answer is A: The sympathetic nervous system saves fluid in response to the stress of surgery. The sympathetic nervous system is responsible for the "fight or flight" response, which includes the conservation of fluids during stressful situations. Dark amber and concentrated urine indicates dehydration, which can be a result of the sympathetic nervous system conserving fluids.
B: The sympathetic nervous system does not "diereses" (increase urination) in response to stress.
C: The parasympathetic nervous system is not involved in fluid conservation during stress.
D: The parasympathetic nervous system does not "diereses" fluid in response to stress.
What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply
- A. Follow agency guidelines to control
- B. Review drug references
- C. Advise the client on modifying the
- D. Monitor client for depression home environment
Correct Answer: E
Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include:
E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively.
Incorrect choices:
A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder.
B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder.
C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder.
D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.