Nokea
Which of the ff points should a nurse include in the teaching plan for clients who have potential for hypovolemia?
- A. Avoid alcohol and caffeine
- B. Increase intake of milk and dairy products
- C. Increase intake of dried peas and beans
- D. Avoid table salt or food containing sodium
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol and caffeine. Alcohol and caffeine are diuretics that can increase urine output, leading to fluid loss and potential hypovolemia. This step is crucial in preventing further dehydration.
Summary of incorrect choices:
B: Increasing milk and dairy products can contribute to fluid intake but does not address the prevention of hypovolemia.
C: While dried peas and beans can provide nutrients, they do not specifically address fluid intake or prevention of hypovolemia.
D: Avoiding table salt or sodium-containing foods may help in reducing fluid retention but does not directly address fluid intake to prevent hypovolemia.
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Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. Risk nursing diagnosis
- B. Actual nursing diagnosis
- C. Possible nursing diagnosis
- D. Wellness diagnosis
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.
Seven girls were victims of food poisoning after eating the sandwiches served at snack time. Which of the following statement are true regarding food poisoning?
- A. Symptoms include salivation, cramping, nausea, vomiting and diarrhea
- B. Foods that are handled and allowed to remain without refrigeration before eaten are most dangerous
- C. Cooking will destroy the organism and stop production of enterotoxin
- D. All are correct
Correct Answer: D
Rationale: Step 1: Symptoms of food poisoning typically include salivation, cramping, nausea, vomiting, and diarrhea, so statement A is correct.
Step 2: Food left unrefrigerated can lead to bacterial growth, making it more dangerous, so statement B is accurate.
Step 3: Cooking can kill harmful organisms and stop the production of toxins, supporting statement C.
Step 4: All three statements are true and collectively provide a comprehensive understanding of food poisoning, making option D the correct answer.
Which of the following is an important preventive factor that the nurse should teach a client with rhinitis?
- A. Not to blow the nose
- B. Not to lift objects weighing more than 5-10 lb
- C. To consume small doses of ice chips
- D. To wash hands frequently
Correct Answer: D
Rationale: The correct answer is D: To wash hands frequently. This is important in rhinitis prevention as it helps reduce the spread of viruses and bacteria that can trigger or exacerbate symptoms. Washing hands removes potential allergens and irritants, reducing the risk of rhinitis flare-ups.
Choice A is incorrect as blowing the nose is necessary to clear mucus and alleviate symptoms. Choice B is irrelevant to rhinitis prevention. Choice C is not directly related to preventing rhinitis.
When caring for Mr. Reyes, the nurse should assess for
- A. Decreased carotid pulses
- B. Altered level of consciousness
- C. Bleeding from oral cavity
- D. Absence of deep tendon-reflexes
Correct Answer: B
Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues.
A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario.
C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness.
D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.