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Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?
- A. Assessment data should be collected continuously.
- B. Assess your client after receiving the nursing report and again before giving a report to the next shift.
- C. Assess your client at least hourly if vital signs are unstable, and every two hours if stable.
- D. Assessment data should be collected prior to the physician rounding on the unit.
Correct Answer: A
Rationale: The correct answer is A because assessment data should be collected continuously to ensure timely detection of any changes in the client's condition. This allows for prompt interventions and prevents complications. Choice B is incorrect as assessment should be ongoing and not limited to specific times. Choice C is incorrect as the frequency of assessment should be based on client needs, not a fixed schedule. Choice D is incorrect as assessments should not be limited to certain times but should be ongoing to provide comprehensive care.
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The nurse administers chemotherapeutic drugs to a client with cancer. What adverse effects are most common?
- A. Painful mouth sores
- B. Nausea and vomiting
- C. Frequent diarrhea
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. Chemotherapeutic drugs commonly cause nausea and vomiting due to their effect on the gastrointestinal system. This is because these drugs can irritate the stomach lining and trigger the vomiting center in the brain. Nausea and vomiting are well-documented side effects of chemotherapy and are often managed with antiemetic medications.
A: Painful mouth sores are a common side effect of some chemotherapeutic drugs, but they are not the most common adverse effect.
C: Frequent diarrhea can occur as a side effect of chemotherapy, but it is less common than nausea and vomiting.
D: Constipation is not a common adverse effect of chemotherapeutic drugs; in fact, diarrhea is more commonly seen.
A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?
- A. “Do you feel like you need to go to the bathroom?”
- B. “Are you able to walk to the bathroom by yourself?”
- C. “When was the last time you took your medicine?” NursingStoreRN
- D. “Do you have a safety rail in your bathroom at home?”
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Asking if the patient feels the need to go to the bathroom helps assess urgency.
2. Urinary retention may lead to the inability to sense the urge to void.
3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention.
Summary:
B: Mobility is not directly related to urinary retention.
C: Medication timing is important but not directly related to urinary retention.
D: Safety rail inquiry is more related to fall prevention, not urinary retention.
A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)
- A. Rank all the patient’s nursing diagnoses in order of priority.
- B. Do not change priorities once they’ve been established.
- C. Set priorities based solely on physiological factors.
- D. Consider time as an influencing factor.
Correct Answer: A
Rationale: The correct answer is A because ranking all the patient's nursing diagnoses in order of priority allows the nurse to address the most critical needs first. By prioritizing based on the urgency and potential impact on the patient's health, the nurse can ensure that interventions are carried out effectively.
B is incorrect because priorities may need to be adjusted based on the patient's changing condition. C is incorrect as priorities should consider not only physiological but also psychological and sociological factors. D is incorrect because time is an influencing factor, but it should not be the sole consideration when prioritizing interventions.
A client, age 42, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?
- A. Onset of sporadic sexual activity at age 17
- B. Spontaneous abortion at age 19
- C. Pregnancy complicated with eclampsia at age 27
- D. Human papilloma virus infection at age 32
Correct Answer: D
Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV infection is a well-known risk factor for cervical cancer as certain strains of HPV can lead to cellular changes in the cervix that may progress to cancer. Here's the rationale:
1. HPV is a known risk factor: HPV is a sexually transmitted infection that is strongly linked to the development of cervical cancer.
2. Age of infection: The client's history of acquiring HPV at age 32 is significant as long-standing HPV infection increases the risk of cervical cancer.
3. Other choices are not directly linked: Choices A, B, and C are not directly associated with an increased risk of cervical cancer. Age of sexual activity onset, spontaneous abortion, and eclampsia are not established risk factors for cervical cancer.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.