Nokea
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care.
Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.
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After being in remission from Hodgkin’s disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin’sdisease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these finding result from:
- A. Bleeding in the liver caused by the liver biopsy.
- B. Perforation of the colon caused by the liver biopsy.
- C. An allergic reaction to the contrast media used during liver biopsy.
- D. Normal post procedural pain, with a change in the level of consciousness resulting from the preexisting fever.
Correct Answer: B
Rationale: The correct answer is B: Perforation of the colon caused by the liver biopsy. The symptoms of fever, severe abdominal pain, and confusion are indicative of peritonitis, which can result from a bowel perforation during the liver biopsy procedure. Perforation of the colon can lead to leakage of bowel contents into the peritoneal cavity, causing inflammation, infection, and systemic symptoms. This is a serious complication that requires immediate medical attention.
Incorrect options:
A: Bleeding in the liver caused by the liver biopsy would present with symptoms such as hypotension and signs of internal bleeding, not confusion and severe abdominal pain.
C: An allergic reaction to contrast media would typically present with symptoms such as rash, itching, or respiratory distress, not fever, severe abdominal pain, and confusion.
D: Normal post procedural pain would not cause confusion and a change in the level of consciousness, which indicates a more serious underlying issue like bowel perforation.
Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
- A. Ease the patient to the floor
- B. Insert a padded tongue depressor between his jaws
- C. Lift the patient and put him on the bed
- D. Restraint patient’s body movement
Correct Answer: A
Rationale: The correct answer is A: Ease the patient to the floor. This is the first step because it helps prevent injury during a seizure. Lowering the patient to the floor prevents falls and protects the patient's head. Choices B, C, and D are incorrect. Choice B can cause injury or obstruct the airway, choice C involves unnecessary movement, and choice D can lead to further harm or injury. It is crucial to prioritize safety and prevent harm during a seizure episode.
Antihistamines are used cautiously in older men with prostatic hypertrophy for which of the ff reasons?
- A. Because the clients may experience increased drowsiness
- B. Because these clients may experience difficulty voiding
- C. Because these clients face a greater risk of cardiac arrest
- D. Because these clients have a lower autoimmune response CARING FOR CLIENTS WITH AIDS
Correct Answer: B
Rationale: The correct answer is B: Because these clients may experience difficulty voiding. Antihistamines can worsen urinary symptoms in men with prostatic hypertrophy by causing urinary retention. This is due to the anticholinergic effects of antihistamines, which can lead to decreased bladder contraction and difficulty in voiding. Increased drowsiness (choice A) is a common side effect of antihistamines but is not specific to older men with prostatic hypertrophy. Choice C, greater risk of cardiac arrest, is not directly related to the use of antihistamines in older men with prostatic hypertrophy. Choice D, lower autoimmune response in clients with AIDS, is unrelated to the use of antihistamines in older men with prostatic hypertrophy.
The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.
Which of the ff instructions should a nurse give a client with Hodgkin’s disease who is at risk of impaired skin integrity? Choose all that apply
- A. Trim nails short
- B. Keep the neck in midline
- C. Use mild soap
- D. Support and protect bony prominences
Correct Answer: B
Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease.
Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area.
Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease.
Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.