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Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
- A. Placement of IV and central venous pressure lines
- B. Administrating cleansing enemas
- C. Observing for leakage of urine or stool from the anastomosis
- D. Assessing the clients ability to manage self catheterization
Correct Answer: C
Rationale: When a client undergoes treatment for a malignant tumor requiring a urinary diversion procedure, such as a urostomy, it is crucial for nurses to closely monitor for any signs of leakage of urine or stool from the anastomosis site. This is important because it can indicate complications such as infection, poor wound healing, or a breakdown in the surgical site. Detecting and addressing leakage promptly can help prevent further complications and ensure the client's recovery progresses smoothly. While the other options may be important aspects of nursing care, observing for leakage of urine or stool from the anastomosis is the most critical factor in managing clients undergoing treatment for a malignant tumor affecting the urinary system.
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An adult is to receive an IM injection of Morphine for post op pain. Which of the following is necessary for the nurse to assess prior to giving a narcotic analgesic?
- A. The client's level of alertness and respiratory rate
- B. The last time the client ate or drank something
- C. The client's bowel habits and last bowel movement
- D. The client's history of addictions
Correct Answer: A
Rationale: When administering a narcotic analgesic like Morphine, assessing the client's level of alertness and respiratory rate is crucial to monitor for any adverse effects such as respiratory depression. Morphine can cause respiratory depression as one of its side effects, especially in higher doses. By assessing the client's respiratory rate and level of alertness before administering the medication, the nurse can ensure the client's safety and take appropriate action if any signs of respiratory depression occur. This assessment is essential in preventing potential complications and ensuring the client's well-being during pain management.
Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: In caring for a patient with expressive aphasia like Mr. Reyea, providing positive feedback when he uses a word correctly is essential for reinforcing and encouraging communication efforts. This positive reinforcement can help boost his confidence and motivation to continue trying to communicate effectively. It is important to support and acknowledge any progress made, as communication difficulties can be frustrating for individuals with aphasia. Waiting for him to verbally state needs regardless of how long it may take, as well as suggesting that he get help at home because the disability is permanent, may not be the most therapeutic or supportive approaches. Helping the family accept that Mr. Reyea cannot participate in verbal communication should not be the primary focus, as there are strategies and therapies that can help improve communication abilities in patients with aphasia.
Aisa is to have blood transfusion. Which of the following problems is most likely associated with blood transfusion?
- A. Serum hepatitis
- B. Pulmonary edema
- C. Allergic response
- D. Hemolytic reaction Situation: Joel is a toddler who has classical hemophilia.
Correct Answer: D
Rationale: A hemolytic reaction is the most likely problem associated with blood transfusion. A hemolytic reaction occurs when the body's immune system attacks the transfused blood, leading to the destruction of red blood cells. This reaction can cause serious complications, including kidney damage, shock, and even death. It is crucial for healthcare providers to carefully match blood types and perform compatibility testing before administering a blood transfusion to minimize the risk of a hemolytic reaction. Serum hepatitis, pulmonary edema, and allergic responses are potential complications of blood transfusions, but hemolytic reactions pose the most immediate and severe threat to the patient's health.
The baby with newly diagnosed diabetes is displaying shakiness, confusion, irritability, and slurred speech. What should the nurse suspect is happening?
- A. DKA
- B. Hypoglycemia
- C. HHS
- D. Hyperglycemia
Correct Answer: B
Rationale: The baby's symptoms of shakiness, confusion, irritability, and slurred speech are indicative of hypoglycemia, which is low blood sugar. In a baby with newly diagnosed diabetes, the administration of insulin or oral hypoglycemic agents may have led to excessive lowering of blood glucose levels, causing these symptoms to manifest. It is crucial to address hypoglycemia promptly by administering a rapid-acting carbohydrate source such as glucose gel or juice to raise blood sugar levels back to normal range. Left untreated, severe hypoglycemia can lead to seizures, loss of consciousness, and potential long-term neurological damage. It is important for healthcare providers and caregivers to be vigilant in monitoring blood glucose levels in babies newly diagnosed with diabetes to prevent episodes of hypoglycemia.
For a 14-month-old whose cleft palate was repaired 12 hours ago, which should be included in the plan of care?
- A. Allow familiar comfort items (e.g., favorite stuffed animal) and a 'sippy' cup (avoid suction items).
- B. Once liquids are tolerated, encourage a bland diet (e.g., soup, Jell-O, saltine crackers).
- C. Administer scheduled pain medication rather than PRN only.
- D. Use a Yankauer suction catheter to decrease aspiration risk.
Correct Answer: A
Rationale: Providing comfort items and avoiding suction items helps reduce distress and supports healing.