Nokea
Which nursing intervention is most appropriate for a client with multiple myeloma?
- A. Monitoring respiratory status
- B. Balancing rest and activity
- C. Restricting fluid intake
- D. Preventing bone injury
Correct Answer: D
Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, bone lesions are common due to bone destruction by abnormal plasma cells. Preventing bone injury is crucial to avoid fractures and bone pain. This can be achieved through careful handling, fall prevention, and avoiding activities that may increase the risk of bone damage. Monitoring respiratory status (A) is not the priority in multiple myeloma. Balancing rest and activity (B) is important but not as critical as preventing bone injury. Restricting fluid intake (C) is not typically necessary unless there are specific indications like renal issues.
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Mr. Kawasaki, a 23-year old industrial worker, was burned severely in an industrial accident. He has second degree burns on his right leg and arm, and on his left leg. He has third degree burns on his left arm. The triage nurse, using the rule of nines, estimates the extent of burn as:
- A. 18%
- B. 45%
- C. 36%
- D. 54%
Correct Answer: C
Rationale: The rule of nines is a method used to estimate the extent of burns on a patient's body. According to this rule, each major body part is assigned a percentage value that represents the total body surface area (TBSA). In this case, Mr. Kawasaki has second-degree burns on his right leg and arm (9% each) and left leg (9%) and third-degree burns on his left arm (9%). Adding these percentages together, we get a total of 36%, which corresponds to the extent of burn on Mr. Kawasaki's body.
Choice A (18%) is incorrect because it only considers one arm and one leg, neglecting the other affected areas. Choice B (45%) is incorrect as it overestimates the extent of burns by including additional body parts not affected. Choice D (54%) is also incorrect as it includes more body parts than those actually burned. Therefore, the correct answer is C (36%) as it accurately reflects the distribution of burns based
Which blood product replaces missing clotting factors in the patient who has a bleeding disorder?
- A. Platelets
- B. Albumin
- C. Packed RBC
- D. Cryoprecipitate
Correct Answer: D
Rationale: The correct answer is D: Cryoprecipitate. Cryoprecipitate contains high levels of clotting factors such as fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor, making it the ideal choice to replace missing clotting factors in patients with bleeding disorders. Platelets (A) help with clot formation but do not contain clotting factors. Albumin (B) is a protein used for volume replacement, not clotting factor replacement. Packed RBC (C) is used to increase oxygen-carrying capacity in anemic patients, not for clotting factor replacement.
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: The correct answer is D because crying whenever diabetes is mentioned indicates emotional distress, a key component of ineffective coping. This response suggests the client is overwhelmed by the diagnosis, affecting their ability to cope effectively. In contrast, choices A, B, and C focus more on physical aspects and management of diabetes, not coping mechanisms. Weight gain could be related to poor diet or medication side effects, skipping insulin doses might indicate non-adherence, and failure to monitor blood glucose could be due to lack of knowledge or resources. Overall, D is the best choice as it directly relates to the client's emotional response to the diagnosis.
The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?
- A. Decreased oral intake and decreased oxygen saturation when ambulating NursingStoreRN Decreased oxygen saturation when ambulating and reports of shortness of breath
- B. when getting out of bed
- C. Reports of shortness of breath when getting out of bed and a productive cough
- D. Productive cough and decreased oral intake
Correct Answer: B
Rationale: Step 1: Activity intolerance is defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities.
Step 2: In the scenario, the patient experiences shortness of breath when getting out of bed, indicating decreased ability to tolerate physical activity.
Step 3: This shortness of breath is a defining characteristic of activity intolerance as it reflects the patient's limited ability to perform activities of daily living.
Step 4: Other symptoms like decreased oral intake, decreased oxygen saturation, and productive cough may be related to other health issues but are not specific to activity intolerance.
Step 5: Therefore, choice B is the correct answer as it includes a key defining characteristic of activity intolerance, while other choices do not directly relate to the concept.
Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
- A. 1, 2, 3, 4
- B. 3, 4, 1, 2
- C. 2, 3, 4, 1
- D. 4, 1, 2, 3
Correct Answer: C
Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.