Nokea
Which nursing action is most appropriate for the weak patient with osteoporosis?
- A. Maintain bedrest
- B. Ambulate with assistance
- C. Encourage fluids
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Ambulate with assistance. Ambulating helps prevent further bone loss and strengthens muscles, important for osteoporosis patients. Bedrest can worsen bone density loss. Encouraging fluids and providing a high-protein diet are important for overall health but do not directly address the weakness associated with osteoporosis.
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A female client age 66 is admitted ff a nephrolithomy. One of her laboratory tests reveals a urinary tract infection. Which would be the best nursing action in her case?
- A. Administer IV fluids and blood transfusions
- B. Administer narcotic analgesics as prescribed
- C. Encourage fluid intake of 3000ml/day
- D. Suggest taking herbs or spices to increase food palatability
Correct Answer: C
Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day
Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation.
Incorrect Choices:
A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection.
B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection.
D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.
An oncology nurse educator is speaking to a women’s group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate?
- A. Mammography is the most reliable method for detecting breast cancer.
- B. Breast cancer is the leading killer of women of childbearing age.
- C. Breast cancer requires a mastectomy.
- D. Men can develop breast cancer.
Correct Answer: D
Rationale: The correct answer is D: Men can develop breast cancer. This is accurate because although breast cancer is more common in women, men can also develop the disease due to the presence of breast tissue in their bodies. This is a crucial point to emphasize to raise awareness about breast cancer among men.
Incorrect choices:
A: Mammography is not the most reliable method for detecting breast cancer, as it may not detect all types of breast cancer.
B: Breast cancer is not the leading killer of women of childbearing age, as there are other leading causes of death in this age group.
C: Breast cancer does not always require a mastectomy; treatment options vary depending on the individual case.
Summary: Choice D is correct as it highlights the important fact that men can also develop breast cancer, which is often overlooked. Choices A, B, and C are incorrect due to inaccuracies or oversimplifications of the facts related to breast cancer detection, statistics, and treatment.
Three days after admission Ms. CC continued to have frequent stools. Her oral intake of both fluids and solids are poor. Her physician ordered parenteral hyperalimentation. Hyperalimentation solutions are:
- A. Hypotonic solutions used primarily to increase osmotic pressure of blood plasma
- B. Hypertonic solutions used primarily for hydration when hemoconcentration is present
- C. Alkalizing solutions used to treat metabolic acidosis thus reducing cellular sweating
- D. Hyperosmolar solutions used primarily to reverse negative nitrogen balance
Correct Answer: D
Rationale: The correct answer is D: Hyperosmolar solutions used primarily to reverse negative nitrogen balance.
Rationale:
1. Hyperalimentation solutions are designed to provide essential nutrients intravenously.
2. Hyperosmolar solutions have a higher osmolarity compared to body fluids, providing concentrated nutrition.
3. Negative nitrogen balance occurs when the body breaks down more protein than it synthesizes, requiring additional protein intake.
4. Hyperosmolar solutions can provide adequate protein and nutrients to reverse negative nitrogen balance.
Summary:
A: Hypotonic solutions do not increase osmotic pressure, but rather decrease it.
B: Hypertonic solutions are not primarily used for hydration in this context.
C: Alkalizing solutions are not the primary purpose of hyperalimentation and do not directly address cellular sweating.
Wilma knew that James have an adequate respiratory condition if she notices that
- A. James’ respiratory rate is 18
- B. James’ Oxygen saturation is 91%
- C. There are frank blood suction from the tube
- D. There are moderate amount of tracheobronchial secretions
Correct Answer: A
Rationale: The correct answer is A because a normal respiratory rate for an adult is typically between 12-20 breaths per minute. A respiratory rate of 18 falls within this range, indicating adequate respiratory function.
Choice B is incorrect because an oxygen saturation of 91% is below the normal range of 95-100%, suggesting potential respiratory insufficiency.
Choice C is incorrect as frank blood suction from the tube indicates a serious issue such as bleeding, not adequate respiratory condition.
Choice D is also incorrect as the presence of a moderate amount of tracheobronchial secretions may indicate a respiratory infection or other respiratory issue, not necessarily adequate respiratory condition.
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
- A. “Choose all the interventions and perform them in order of time needed for each one.”
- B. “Make sure you identify the scientific rationale for each intervention first.”
- C. “Decide on goals and outcomes you have chosen for the patients.”
- D. “Begin with the highest priority diagnoses, then select appropriate interventions.”
Correct Answer: D
Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions."
Rationale:
1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being.
2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery.
3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient.
4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes.
Summary:
A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs.
B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses.
C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.