Nokea
Which of the following is the best indicator of a patient's nutritional status?
- A. Patient's weight
- B. Serum albumin levels
- C. Patient's food preferences
- D. Number of meals consumed per day
Correct Answer: B
Rationale: The correct answer is B: Serum albumin levels. Serum albumin is a protein produced by the liver and is a key indicator of a patient's nutritional status. Low levels of serum albumin indicate malnutrition or protein deficiency. Monitoring serum albumin levels provides an objective measure of the patient's overall nutritional status.
Choice A (Patient's weight) can be influenced by factors other than nutrition, such as fluid retention or muscle mass. Choice C (Patient's food preferences) does not provide direct information on the patient's actual nutritional intake. Choice D (Number of meals consumed per day) does not account for the quality or quantity of nutrients consumed in those meals.
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A nurse is caring for a patient with a history of hypertension and heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
- A. Increased urine output and weight loss.
- B. Swelling in the legs and shortness of breath.
- C. Decreased blood pressure and dizziness.
- D. Fatigue and constipation.
Correct Answer: B
Rationale: The correct answer is B: Swelling in the legs and shortness of breath. In heart failure, fluid can build up in the body causing swelling, particularly in the legs. Shortness of breath is a common symptom due to fluid accumulation in the lungs. Increased urine output and weight loss (A) are not indicative of worsening heart failure as they suggest fluid loss. Decreased blood pressure and dizziness (C) can be seen in other conditions like dehydration. Fatigue and constipation (D) are not specific signs of heart failure worsening.
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should encourage the patient to:
- A. Avoid deep breathing exercises to prevent pain.
- B. Take shallow breaths to minimize pain.
- C. Perform deep breathing exercises to prevent pneumonia.
- D. Limit mobility to avoid stress on the surgical site.
Correct Answer: C
Rationale: Step 1: Post-operative patients are at risk for developing pneumonia due to decreased lung expansion and secretion retention.
Step 2: Deep breathing exercises help improve lung expansion and prevent pneumonia.
Step 3: Therefore, encouraging the patient to perform deep breathing exercises is essential.
Summary:
- A: Avoiding deep breathing exercises is incorrect as it can lead to respiratory complications.
- B: Taking shallow breaths can worsen lung function and increase the risk of pneumonia.
- D: Limiting mobility can lead to complications like blood clots and pneumonia.
A nurse is teaching a patient with diabetes about insulin administration. Which of the following actions should the nurse emphasize to the patient?
- A. Store insulin at room temperature to prevent crystallization.
- B. Use insulin immediately after drawing it up into the syringe.
- C. Inject insulin into the same spot to avoid tissue damage.
- D. Rotate injection sites to prevent lipodystrophy.
Correct Answer: D
Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications.
A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration.
B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations.
C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.
Which of the following statements represents subjective data about the patient's skin?
- A. Skin dry in appearance
- B. No obvious lesions
- C. Denies colour change
- D. Lesion noted lateral aspect right arm
Correct Answer: C
Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.
A nurse is teaching a patient about managing chronic pain. Which of the following strategies should the nurse emphasize?
- A. Increasing activity to improve function.
- B. Using medications only when absolutely necessary.
- C. Implementing physical therapy and exercises.
- D. Using complementary therapies such as meditation and relaxation.
Correct Answer: C
Rationale: The correct answer is C: Implementing physical therapy and exercises. This is crucial for managing chronic pain as it helps improve strength, flexibility, and overall function. Physical therapy can also address underlying issues contributing to pain. Choice A could worsen pain if not done appropriately. Choice B may be necessary but should not be the sole approach. Choice D can be beneficial but may not address the root cause of pain like physical therapy does.