Nokea
Which of the following statements does NOT apply to a nursing plan of care?
- A. It contains short-term goals
- B. It is developed by the patient's physician
- C. It must be continually evaluated
- D. It contains long-range goals
Correct Answer: B
Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.
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Participating in the development of long-term and preventive health goals with the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: B
Rationale: The correct answer is B: Planning. Planning in nursing care involves setting long-term and preventive goals for the patient in collaboration with the patient and their family. This step ensures that a comprehensive and individualized care plan is developed. Choice A, Evaluation, comes after the interventions have been implemented to assess their effectiveness. Choice C, Implementation, is the step where the care plan is put into action. Choice D, Assessment, is the initial step that involves collecting data to identify the patient's needs, which is done before planning the care.
The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?
- A. The client's BP is 110/70
- B. The client's potassium level is 3.4 mEq/L
- C. The client has a barky cough
- D. The client's apical pulse is 56
Correct Answer: D
Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering a beta blocker as the blood pressure is within normal range. Choice B is not directly related to the administration of a beta blocker. Choice C may indicate a potential adverse effect of another medication, but it does not specifically warrant questioning the administration of the beta blocker.
The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?
- A. Establish a rapport with the client to decrease embarrassment during site assessment
- B. Encourage the client to lie in the lithotomy position twice a day
- C. Milk the tube inserted during surgery to facilitate the passage of flatus
- D. Digitally dilate the rectal sphincter to express old blood
Correct Answer: A
Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.
After undergoing a pericardiocentesis, which interventions should the nurse implement?
- A. Monitor vital signs every 15 minutes for the first hour
- B. Evaluate the client's cardiac rhythm
- C. Record the amount of fluid removed as output
- D. All of the above
Correct Answer: D
Rationale: Following a pericardiocentesis, it is crucial for the nurse to monitor vital signs regularly, evaluate cardiac rhythm, and record the amount of fluid removed as output to detect any complications promptly. These interventions help in ensuring the client's safety and detecting any potential issues early. Therefore, selecting 'All of the above' (Choice D) is the correct answer as it encompasses all the essential interventions required post-pericardiocentesis. Choices A, B, and C are necessary actions to provide comprehensive care and monitor the client effectively.
What condition should a patient on long-term steroid therapy be monitored for?
- A. Hyperglycemia
- B. Hypothyroidism
- C. Hypertension
- D. Osteoporosis
Correct Answer: D
Rationale: Correct! Patients on long-term steroid therapy should be monitored for osteoporosis. Prolonged use of steroids can lead to decreased bone density, increasing the risk of osteoporosis. Hyperglycemia is more commonly associated with steroid-induced diabetes rather than long-term steroid use. Hypothyroidism is not a typical complication of long-term steroid therapy. While steroids can contribute to hypertension, osteoporosis is a more prominent concern in this scenario.