Nokea
Which of the ff. nursing actions is most appropriate when doing perineal care on an uncircumcised male patient?
- A. Leave the foreskin retracted so air can keep the area dry
- B. Do not retract the foreskin during washing
- C. Replace the foreskin over the head of the penis after washing
- D. Use alcohol and a cotton swab to clean under the foreskin
Correct Answer: C
Rationale: The correct answer is C, which is to replace the foreskin over the head of the penis after washing. This is important to prevent any irritation or injury to the sensitive foreskin and glans. Leaving the foreskin retracted (A) can lead to discomfort and potential injury. Not retracting the foreskin (B) may not allow for proper cleaning. Using alcohol and a cotton swab (D) can be too harsh and irritating to the delicate tissues. Therefore, option C is the most appropriate and gentle approach to maintain proper hygiene and prevent any complications.
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The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
The nurse is caring for a client in the emergency room diagnosed with Bell’s palsy. The client has been taking acetaminophen (Tylenol), and acetaminophen overdose is suspected. The nurse anticipates that the antidote to be prescribed is:
- A. Pentostatin (Nipent)
- B. Fludarabine (Fludara)
- C. Auranofin (Ridaura)
- D. Acetylcysteine Mucomyst)
Correct Answer: D
Rationale: Rationale: Acetylcysteine (Mucomyst) is the antidote for acetaminophen overdose. It works by replenishing glutathione, which helps neutralize the toxic metabolite of acetaminophen. Pentostatin, Fludarabine, and Auranofin are not antidotes for acetaminophen overdose and are used for different conditions. Acetylcysteine is the correct choice as it directly counteracts the toxic effects of acetaminophen.
Which of the following hormones retains sodium in the body?
- A. Antidiuretic hormone
- B. Aldosterone
- C. Thyroid hormone
- D. Insulin
Correct Answer: B
Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance.
A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention.
C: Thyroid hormone does not directly influence sodium retention.
D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.
A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: C
Rationale: The correct answer is C: Implementation. In this step of the nursing process, the nurse is carrying out the care plan based on the identified nursing diagnoses. The nurse is actively providing care and interventions to meet the patient's needs.
Assessment (A) is the initial step where data is collected and analyzed. Planning (B) is where goals and interventions are determined based on assessment findings. Evaluation (D) is the final step where the nurse assesses the effectiveness of the care provided.
In this scenario, the nurse has already completed the care plan and is now executing the plan by implementing the interventions, making choice C the correct answer.
A client in the final stages of terminal cancer tells the nurse: “I wish I could be just be allowed to die. I’m tired of fighting this illness. I have lived life a good life. I only continue my chemotherapy and radiation treatment because my family wants me to.” What is the best nurse’s best response?
- A. “Would you like to talk to a psychologist about your thoughts and feelings?”
- B. “Would you like to talk to your minister about the significance of death?”
- C. “Would you like to meet with your family and your physician about this matter?”
- D. “I know you are tired of fighting this illness, but death will come in due time.”
Correct Answer: C
Rationale: The correct response is C: “Would you like to meet with your family and your physician about this matter?”
Rationale:
1. Involving the family and physician ensures a collaborative decision-making process.
2. It respects the client's autonomy and involves them in the decision-making process.
3. It promotes open communication and support from loved ones.
4. It addresses the client's concerns about continuing treatment based on family wishes.
Summary:
A: Refers to psychological support, but the client's primary concern is medical treatment decisions.
B: Involves religious support, which may not align with the client's beliefs or address the medical decision.
D: Acknowledges the client's feelings but lacks a collaborative approach involving family and healthcare team.