Nokea
Which patient would benefit most from a capped IV catheter that is used intermittently rather than continuously?
- A. The patient with pneumonia who needs fluids and antibiotics.
- B. The patient who has had major blood loss after a motor vehicle accident.
- C. The young child who is dehydrated.
- D. The elderly patient who is receiving a diuretic for fluid overload.
Correct Answer: D
Rationale: The correct answer is D, the elderly patient receiving a diuretic for fluid overload. This patient would benefit most from a capped IV catheter used intermittently because diuretics can lead to fluctuations in fluid balance that require careful monitoring and adjustment of IV fluids. By using the catheter intermittently, healthcare providers can better control the amount of fluid administered to prevent electrolyte imbalances.
Option A is incorrect because a patient with pneumonia requiring fluids and antibiotics would likely benefit from a continuous IV to maintain stable levels of medications and hydration. Option B is incorrect as a patient with major blood loss would require continuous IV fluids to restore blood volume. Option C is incorrect as a dehydrated young child would also benefit from continuous IV fluids to rehydrate effectively.
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A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
- A. “I’ll play card games with my friends.”
- B. “I’ll bowl with my team after discharge.”
- C. “I’ll take a long trip to visit my aunt.”
- D. “I’ll eat lunch in a restaurant everyday.”
Correct Answer: A
Rationale: The correct answer is A because playing card games with friends is a low-energy activity suitable for someone with decreased energy due to chemotherapy. This option promotes social interaction and mental stimulation, addressing the deficient diversional activity.
B, bowling with a team, involves physical activity and may be too strenuous for someone with decreased energy. C, taking a long trip, requires significant energy and may not be feasible. D, eating lunch in a restaurant, does not address the need for diversional activity and is not specific to the client's energy limitations.
A 45-year-old patient has a long- standing history of allergies to pollen. Which of the following actions indicates that the patient does not understand how to control this disease?
- A. Staying indoors on dry, windy days.
- B. Refusing to walk outside in the spring.
- C. Driving in the care with the windows open.
- D. Working in the garden on sunny days.
Correct Answer: C
Rationale: The correct answer is C. Driving in the car with the windows open exposes the patient to pollen, worsening allergies. Staying indoors on dry, windy days (A) reduces exposure. Refusing to walk outside in spring (B) also minimizes exposure. Working in the garden on sunny days (D) increases pollen exposure. Therefore, choice C is the only action that goes against controlling pollen allergies.
As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
- A. I know the hallucinations are parts of the disease
- B. I told her she is wrong and I explained to her what is right
- C. I help her do some tasks he cannot do for himself
- D. Ill turn off the TV when we go to another room
Correct Answer: B
Rationale: The correct answer is B because it indicates a confrontational and potentially disrespectful attitude towards the nurse. This response does not promote a collaborative and respectful communication between the daughter and the nurse. In a healthcare setting, it is important for family members to communicate effectively and respectfully with the healthcare team to ensure the best care for the patient.
A: This statement shows understanding and acceptance of the symptoms of the disease, indicating good knowledge.
C: This statement shows willingness to help the patient with tasks he cannot do for himself, which is a positive and caring attitude.
D: This statement shows consideration for the patient's needs by planning to turn off the TV when moving to another room, which is appropriate.
When caring for Mr. Reyes, the nurse should assess for
- A. Decreased carotid pulses
- B. Altered level of consciousness
- C. Bleeding from oral cavity
- D. Absence of deep tendon-reflexes
Correct Answer: B
Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues.
A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario.
C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness.
D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.