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While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client’s chart. Which of the following actions clearly demonstrates assessing?
- A. The nurse bathing the client
- B. The nurse documenting the incident
- C. The nurse asking if the client is having pain
- D. The nurse removing the wash basin
Correct Answer: C
Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being.
A: The nurse bathing the client is not an action of assessment but rather a task related to providing care.
B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition.
D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.
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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.
Which action will the nurse take after the plan of care for a patient is developed?
- A. Place the original copy in the chart, so it cannot be tampered with or revised.
- B. Communicate the plan to all health care professionals involved in the patient’s care.
- C. File the plan of care in the administration office for legal examination. NursingStoreRN
- D. Send the plan of care to quality assurance for review.
Correct Answer: B
Rationale: The correct answer is B because after developing a plan of care, the nurse must communicate it to all healthcare professionals involved in the patient's care to ensure everyone is aware of the plan and can collaborate effectively. This promotes continuity of care and prevents errors.
Choice A is incorrect because the plan of care should not be placed in the chart to avoid tampering; it should be easily accessible for updates. Choice C is incorrect as filing in the administration office is unnecessary for routine care. Choice D is incorrect as sending the plan to quality assurance is not the immediate next step after developing the plan.
A client metastatic ovarian cancer is prescribed cisplatin (Platinol). Before administering the first dose, the nurse reviews the client’s medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin?
- A. Erythromycin
- B. A cephalosporin
- C. A tetracycline
- D. An amino glycoside Situation: A client with ovarian cancer is prescribed hydroxyurea (Hydrea), an antimetabolite drug.
Correct Answer: D
Rationale: The correct answer is D: An aminoglycoside. Aminoglycosides, such as gentamicin or amikacin, can interact with cisplatin by increasing the risk of nephrotoxicity and ototoxicity. Both cisplatin and aminoglycosides have the potential to cause kidney damage, and when used together, the risk of kidney toxicity is significantly increased. This interaction is due to the additive effects on the kidneys. Therefore, it is crucial to monitor renal function closely and adjust the dosages of these drugs accordingly to prevent severe adverse effects.
Summary:
A: Erythromycin - Erythromycin is not known to have significant interactions with cisplatin.
B: A cephalosporin - Cephalosporins do not typically interact with cisplatin in a clinically significant manner.
C: A tetracycline - Tetracyclines are not known to cause significant interactions with
Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?
- A. Increased urine output
- B. Dyspnea on exertion
- C. Swollen joints
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.
A home care nurse is assessing a client who is taking prazosin (Minipress). Which statement by the client would support the nursing diagnosis of noncompliance with medication therapy?
- A. “I don’t’d understand why I have to keep taking pills when my blood pressure is normal.”
- B. “I can’t see the numbness on the label to know how much selt is in food.”
- C. “I feel dizzy, I’ll skip my dose foe a few days.”
- D. “If I have a cold, I shouldn’t take any over-the-counter remedies without consulting my doctor.”
Correct Answer: C
Rationale: Step 1: Identify the correct answer - C: “I feel dizzy, I’ll skip my dose for a few days.”
Step 2: Explanation - This statement indicates that the client is experiencing a known side effect of prazosin (dizziness) and plans to stop the medication temporarily without consulting the healthcare provider, showing noncompliance.
Step 3: Supporting details - Skipping doses can lead to ineffective treatment and potential health risks.
Step 4: Comparison with other choices:
A: This statement shows the client questioning the need for medication but does not indicate current noncompliance.
B: This statement demonstrates difficulty reading labels but does not directly relate to medication compliance.
D: This statement shows awareness about medication interactions but does not indicate noncompliance with the prescribed medication regimen.
Summary: Choice C is correct as it directly reflects noncompliance by planning to skip doses without consulting the healthcare provider, leading to potential adverse outcomes. Choices A, B, and D do not demonstrate the