Nokea
Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
- A. “Data interpretation occurs before data validation.”
- B. “Validation involves looking for patterns in professional standards.”
- C. “Validation involves comparing data with other sources for accuracy.”
- D. “Data interpretation involves discovering patterns in professional standards.”
Correct Answer: C
Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This process checks for errors, inconsistencies, and completeness in the data. By comparing data with other sources, nurses can verify the reliability and correctness of the information.
Choice A is incorrect because data validation typically occurs after data collection and before data interpretation. Choice B is incorrect because validation is about ensuring data accuracy, not about professional standards. Choice D is incorrect because data interpretation focuses on analyzing and making sense of the data, not on professional standards or validation processes.
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Which of the following patients should the nurse monitors because of increased risk for surgical complications?
- A. 25-year old with appendicitis
- B. patient 5’3” in height, weight 180 lbs
- C. 12-year old with fractured knee
- D. 17-year old with gallstone
Correct Answer: B
Rationale: The correct answer is B because the patient's Body Mass Index (BMI) indicates obesity, putting them at higher risk for surgical complications. Obesity is associated with increased risks of infections, delayed wound healing, respiratory issues, and cardiovascular problems post-surgery. Monitoring this patient closely is crucial.
Choice A is less likely to have increased surgical complications due to age and condition. Choice C, a 12-year-old, is less likely to have significant surgical complications compared to adults. Choice D, a 17-year-old with gallstones, may have risks but the BMI of the patient in choice B indicates a higher risk.
The nurse understands that which of the ff. best describes the action of enalapril maleate (Vasotec)?
- A. It decreases levels of angiotensin II
- B. It dilates the arterioles and veins
- C. It adjusts the extracellular volume
- D. It decreases cardiac output
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor.
2. ACE inhibitors like enalapril maleate block the conversion of angiotensin I to angiotensin II.
3. By inhibiting the formation of angiotensin II, enalapril maleate decreases the levels of angiotensin II.
4. Angiotensin II is a potent vasoconstrictor, so decreasing its levels leads to vasodilation and decreased blood pressure.
Summary of why other choices are incorrect:
- Choice B: Enalapril maleate primarily dilates arterioles by decreasing angiotensin II levels, not veins.
- Choice C: Enalapril maleate does not directly adjust extracellular volume; it primarily affects the renin-angiotensin-aldosterone system.
- Choice D: Enalapril maleate
The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
- A. Ask the nursing assistive personnel if the wound looks better.
- B. Document the progress of wound healing as “better” in the chart.
- C. Measure the wound and observe for redness, swelling, or drainage.
- D. Leave the dressing off the wound for easier access and more frequent assessments.
Correct Answer: C
Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications.
- Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately.
- Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status.
- Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.
The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
- A. Hyperkalemia
- B. Hypernatremia
- C. Reduced blood urea nitrogen (BUN)
- D. Hyperglycemia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to electrolyte imbalances. This results in increased potassium levels (hyperkalemia) due to lack of aldosterone to promote potassium excretion. Hypernatremia (choice B) is less likely as aldosterone deficiency leads to sodium loss. Reduced BUN (choice C) is unlikely as Addison's crisis does not directly affect urea levels. Hyperglycemia (choice D) is not typically seen in Addisonian crisis as cortisol deficiency usually results in hypoglycemia.
The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient’s face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: Rationale: A relaxed face during conversation typically does not indicate a hearing loss, as the patient is likely able to hear and understand. B, speaking loudly, is a common sign of hearing loss. C, turning towards the speaker, suggests an effort to hear better. D, being withdrawn, could indicate difficulty in communication due to hearing loss. Therefore, A is the correct answer as it does not align with typical signs of hearing loss.