Nokea
Which of the following actions should the nurse take to maintain patient safety when ambulating a patient for the first time postoperatively?
- A. Use one person to assist patient.
- B. Use two people to assist patient.
- C. Encourage patient to “dangle” self 1 hour before ambulation.
- D. Give narcotic 15 minutes before ambulation.
Correct Answer: B
Rationale: The correct answer is B: Use two people to assist the patient. This is the safest option as it provides optimal support and stability for the patient during their first postoperative ambulation. Two people can help prevent falls, ensure proper body mechanics, and offer immediate assistance if needed. Using one person (choice A) may not provide enough support. Encouraging the patient to "dangle" (choice C) may increase the risk of orthostatic hypotension. Giving a narcotic before ambulation (choice D) can impair the patient's balance and coordination, increasing the risk of falls.
You may also like to solve these questions
The nurse knows which of the following is true about immunity?
- A. Antibody-mediated defense occurs through the T-cell system
- B. Cellular immunity is mediated by antibodies produced by the B-cells
- C. Antibodies are produced by the B-cells
- D. Lymphocytes increase with an allergic response
Correct Answer: C
Rationale: Rationale:
Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens.
Incorrect Choices:
A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity.
B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells.
D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan.
Now, let's analyze the other choices:
A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.
A client is admitted for a spelenectomy. What problem is the nurse aware that could develop?
- A. Infection
- B. Urinary retention
- C. Congestive heart failure
- D. Viral hepatitis
Correct Answer: A
Rationale: The correct answer is A: Infection. After a splenectomy, the client is at risk for infection due to the spleen's role in the immune system. Without the spleen, the body's ability to fight infections is reduced. Infections can be serious and life-threatening.
B: Urinary retention is not a typical complication of a splenectomy.
C: Congestive heart failure is not directly related to a splenectomy.
D: Viral hepatitis is not a common complication of a splenectomy.
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.
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
- A. low fat low cholesterol
- B. low sodium diet
- C. bland soft diet
- D. high calorie high protein
Correct Answer: D
Rationale: The correct answer is D: high calorie high protein. In COPD exacerbation, the body requires extra calories and protein for energy and muscle strength. High-calorie foods help combat weight loss and fatigue. High-protein foods aid in muscle repair and maintenance. Low-fat low-cholesterol (A) is not ideal as healthy fats are needed. Low-sodium (B) is not necessary unless there is concurrent heart failure. Bland soft diet (C) is not suitable as it does not provide enough calories and protein needed for COPD exacerbation.