Nokea
Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?
- A. Do not leave the patient unattended at any time.
- B. Teach the patient not to bend over.
- C. Report sudden onset of acute pain.
- D. Apply sandbags to either side of the head.
Correct Answer: C
Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications.
A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain.
B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain.
D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.
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A client with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U- 100 regular insulin and 35 U of 100-U isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
- A. “Inject insulin into healthy tissue with large blood vessels and nerves.”
- B. “Rotate injection sites within the same anatomic region, not among different regions.”
- C. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
- D. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”
Correct Answer: B
Rationale: The correct answer is B: “Rotate injection sites within the same anatomic region, not among different regions.” This instruction is important to prevent lipodystrophy and ensure consistent insulin absorption. Rotating sites within the same region helps maintain consistent insulin absorption rates and reduces the risk of developing scar tissue or fatty deposits. Injecting into healthy tissue with large blood vessels and nerves (choice A) can lead to inconsistent absorption. Administering insulin into areas of scar tissue or hypotrophy (choice C) can also disrupt absorption. Injecting into sites above muscles planned for exercise (choice D) can lead to unpredictable insulin absorption. Rotation within the same region optimizes insulin delivery and prevents complications.
Which action best demonstrates the nurse’s role in ensuring continuity of care during the evaluation phase?
- A. Rewriting the care plan based on current findings.
- B. Communicating the client’s progress to the interdisciplinary team.
- C. Reassessing the client to gather additional data.
- D. Providing emotional support to the client and family.
Correct Answer: B
Rationale: The correct answer is B: Communicating the client’s progress to the interdisciplinary team. During the evaluation phase, the nurse plays a crucial role in ensuring continuity of care by effectively communicating the client’s progress to the interdisciplinary team. This action allows for collaborative decision-making based on the latest information, promotes coordination of care, and ensures that all team members are informed and involved in the client's care plan. Rewriting the care plan (A) is important but may not be the most immediate action during the evaluation phase. Reassessing the client (C) is valuable for gathering additional data but may not directly contribute to continuity of care during this phase. Providing emotional support (D) is essential but may not specifically address continuity of care during evaluation.
The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has two young children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?
- A. Tell the client’s spouse or partner to be supportive while she recovers.
- B. Encourage the client to proceed with the next phase of treatment.
- C. Recommend that the client remain cheerful for the sake of her children.
- D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.
Correct Answer: D
Rationale: The correct answer is D: Refer the client to the American Cancer Society’s Reach for Recovery program or another support program. This choice is the best option as it provides the client with additional support and resources specifically tailored to individuals coping with cancer and mastectomy. The Reach for Recovery program offers emotional support, education, and practical assistance which can immensely benefit the client during this challenging time.
A: Involving the client's spouse or partner is important, but support programs like Reach for Recovery can offer specialized assistance that may not be fully covered by the spouse's support alone.
B: While proceeding with the next phase of treatment is important, emotional support and coping mechanisms are equally crucial, which support programs can provide.
C: Asking the client to remain cheerful may put pressure on her and may not address her emotional needs adequately, unlike a support program that is designed to provide comprehensive support.
A hospital’s wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient’s dressing changes. Which action should the nurses take next?
- A. Include dressing change instructions and frequency in the care plan.
- B. Assume that the wound nurse will perform all dressing changes.
- C. Request that the health care provider look at the wound.
- D. Encourage the patient to perform the dressing changes.
Correct Answer: A
Rationale: The correct answer is A: Include dressing change instructions and frequency in the care plan. This is the correct action because it ensures consistency in care and communication among the nursing team. By documenting the dressing change instructions and frequency in the care plan, all nurses will have clear guidance on how to perform the dressing changes correctly and at the appropriate intervals. This promotes continuity of care and helps prevent errors or omissions in the dressing change process.
Option B is incorrect as it is not realistic to expect the wound nurse to perform all dressing changes. Option C is unnecessary unless there are specific concerns requiring the health care provider's attention. Option D is not appropriate as encouraging the patient to perform dressing changes may not be safe or feasible depending on the patient's condition.
A woman sees her primary care provider because of extreme fatigue for the past 2 months; she difficulty lifting even light objects. Her physician suspects myasthenia gravis. Which of the ff. tests should the nurse anticipate to confirm this diagnosis?
- A. Mestinon test
- B. Pulmonary function studies
- C. Quinine tolerance test
- D. Tensilon test
Correct Answer: D
Rationale: The correct answer is D: Tensilon test. The Tensilon test involves administering edrophonium (Tensilon) to temporarily improve muscle weakness in myasthenia gravis patients, confirming the diagnosis. Other choices are incorrect: A (Mestinon test) is not a standard diagnostic test for myasthenia gravis, B (Pulmonary function studies) are not specific for myasthenia gravis, and C (Quinine tolerance test) is not a relevant test for this condition.