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Which of the following lab value profiles should the nurse know to be consistent with hemolytic anemia?
- A. Increased RBC, decreased bilirubin, decreased Hgb and Hct, increased reticulocytes
- B. Decreased RBC, increased bilirubin, decreased Hgb and Hct, increased reticulocytes
- C. Decreased RBC, decreased bilirubin, increased Hgb and Hct, decreased reticulocytes
- D. Increased RBC, increased bilirubin, increased Hgb and Hct, decreased reticulocytes
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer (A):
1. Increased RBC: Hemolytic anemia leads to increased RBC production as the body compensates for the destruction of red blood cells.
2. Decreased bilirubin: Bilirubin levels decrease due to the accelerated breakdown of red blood cells.
3. Decreased Hgb and Hct: Hemolysis causes a decrease in hemoglobin and hematocrit levels as red blood cells are destroyed.
4. Increased reticulocytes: Reticulocytes are immature red blood cells released by the bone marrow in response to increased RBC destruction.
Summary:
- Choice B is incorrect as hemolytic anemia would lead to increased, not decreased, bilirubin levels.
- Choice C is incorrect as hemolytic anemia would lead to decreased, not increased, Hgb and Hct levels.
- Choice D is incorrect as hemolytic anemia would not lead to increased levels of all parameters
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A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, “I have been so constipated lately.” How should the nurse respond?
- A. “Do you have a family history of chest problems?”
- B. “Why don’t you use a laxative every night?”
- C. “Do you take anything to help your constipation?”
- D. “Everyone who ages has bowel problems.”
Correct Answer: C
Rationale: The correct answer is C. The nurse should respond by asking, “Do you take anything to help your constipation?” This response shows active listening and gathers more information about the woman’s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes.
Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A because completing a comprehensive database is part of the first phase of the nursing process, which is assessment. During assessment, the nurse gathers data about the patient's health status. This information is crucial for identifying health problems, developing nursing diagnoses, planning interventions, and evaluating outcomes.
Choice B is incorrect because identifying nursing diagnoses is part of the second phase, which is diagnosis. Choice C is incorrect as intervening based on priorities of patient care is part of the third phase, which is planning. Choice D is incorrect because determining whether outcomes have been achieved is part of the fourth phase, which is evaluation.
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
- A. Stand as far away from the implant as possible and call for help.
- B. Pick up the implant with long-handled forceps and place it in a lead-lined container.
- C. Leave the room and notify the radiation therapy department immediately.
- D. Put the implant back in place, using forceps and a shield for self-protection, and call for help.
Correct Answer: D
Rationale: The correct answer is D. First, the nurse should put the implant back in place using forceps and a shield for self-protection. This is important to limit the exposure to radiation for both the client and the nurse. Second, the nurse should call for help to ensure proper handling and further assistance. Standing away from the implant (choice A) does not address the immediate need to secure the implant. Picking up the implant with long-handled forceps and placing it in a lead-lined container (choice B) should only be done by trained personnel to prevent further exposure. Leaving the room and notifying the radiation therapy department immediately (choice C) delays the immediate action needed to prevent unnecessary radiation exposure.
Which of the following intravenous solutions is hypotonic?
- A. Normal saline
- B. Ringer’s lactate
- C. 0.45% saline
- D. 5% dextrose in normal saline A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET F
Correct Answer: C
Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell.
Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts.
5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
- A. Anxiety related to barium enema
- B. Impaired gas exchange related to asthma
- C. Impaired physical mobility related to incisional pain
- D. Nausea related to adverse effect of cancer medication
Correct Answer: A
Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs.
Summary:
B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition.
C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself.
D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.