Nokea
Which of the ff nursing interventions is essential for a client during the Schilling test?
- A. Collecting urine 24-48 hrs after the client has received nonradioactive B12
- B. Collecting blood samples of 50 ml for 24-48 hrs after the client has received the nonradioactive B12
- C. Not allowing any oral fluid consumption for 24-48 hrs after the client has received nonradioactive B12
- D. Making the client lie down in the supine position for 24-48 hrs after the client has received nonradioactive B12 CARING FOR CLIENTS WITH DISORDERS OF THE HEMATOPOIETIC SYSTEM
Correct Answer: A
Rationale: The correct answer is A because collecting urine 24-48 hrs after the client has received nonradioactive B12 is essential for the Schilling test to evaluate vitamin B12 absorption. Urine is collected to measure the excretion of radioactive B12, which helps in diagnosing pernicious anemia or malabsorption issues.
Incorrect choices:
B: Collecting blood samples is not necessary for the Schilling test as it primarily involves urine collection.
C: Allowing oral fluid consumption is important to prevent dehydration and is not contraindicated after receiving nonradioactive B12.
D: Making the client lie down in the supine position is unnecessary for the Schilling test and may not affect the test results.
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Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Expiratory wheezes
- C. Friction rub
- D. Fluid in the involved area
Correct Answer: D
Rationale: The correct answer is D because pleural effusion is the accumulation of fluid in the pleural space. When auscultating the lungs of a client with pleural effusion, the examiner would note decreased or absent breath sounds over the area where the fluid has accumulated. This is due to the fluid blocking the transmission of sound through the lungs. Pronounced breath sounds (choice A) would not be present due to the fluid obstructing the normal sound transmission. Expiratory wheezes (choice B) are associated with airway obstruction, not fluid accumulation. Friction rub (choice C) is a dry, grating sound heard with inflammation of the pleura, not specifically related to pleural effusion.
or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. “Client verbalizes feelings of anxiety.”
- B. “Client doesn’t guess at prognosis.”
- C. “Client uses any effective method to reduce tension.”
- D. “Client stops seeking information.”
Correct Answer: A
Rationale: The correct answer is A because it reflects a measurable and client-centered outcome. Verbalizing feelings of anxiety indicates the client is acknowledging and addressing their emotions, which is essential in managing anxiety. Choice B is incorrect as it focuses on avoidance rather than expression of emotions. Choice C is incorrect as it doesn't specify the use of appropriate coping mechanisms. Choice D is incorrect as it suggests avoidance of seeking information, which may hinder the client's understanding and coping with the diagnosis.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
The lowest fasting plasma glucose level suggestive of a diagnosis of diabetes is:
- A. 90mg/dl
- B. 126mg/dl
- C. 115mg/dl
- D. 180mg/dl
Correct Answer: B
Rationale: The correct answer is B (126mg/dl) because a fasting plasma glucose level ≥126mg/dl is diagnostic of diabetes. The diagnostic criteria for diabetes include a fasting plasma glucose level ≥126mg/dl on two separate occasions. Choices A, C, and D are incorrect because they do not meet the diagnostic threshold for diabetes. A (90mg/dl) is within the normal range, C (115mg/dl) is elevated but not diagnostic, and D (180mg/dl) is too high but not necessary for diagnosis. It's crucial to understand the specific diagnostic criteria to accurately identify diabetes.
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, “I have been so constipated lately.” How should the nurse respond?
- A. “Do you have a family history of chest problems?”
- B. “Why don’t you use a laxative every night?”
- C. “Do you take anything to help your constipation?”
- D. “Everyone who ages has bowel problems.”
Correct Answer: C
Rationale: The correct answer is C. The nurse should respond by asking, “Do you take anything to help your constipation?” This response shows active listening and gathers more information about the woman’s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes.
Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.