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While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
- A. Immediately place the patient in isolation.
- B. Ask the patient to describe the type of reaction.
- C. Proceed to the termination phase of the interview.
- D. Document the latex allergy on the medication administration record.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take to assess the severity of the latex allergy and determine appropriate interventions. By gathering more information about the reaction, the nurse can better understand the potential risks and provide safe care.
Summary of other choices:
A: Immediately placing the patient in isolation is unnecessary and not indicated based solely on the patient's latex allergy.
C: Proceeding to the termination phase of the interview is premature without fully assessing the patient's allergy.
D: Documenting the allergy is important but should not be the first action without assessing the reaction itself.
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What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system?
- A. Kardex care plans
- B. Computerized plans of care
- C. Clinical pathways
- D. Student care plans
Correct Answer: C
Rationale: The correct answer is C: Clinical pathways. Clinical pathways are standardized, evidence-based interdisciplinary plans of care used in case management to guide the treatment and management of clients. They outline the expected course of treatment, interventions, and outcomes for specific health conditions. Kardex care plans (A) are outdated paper-based patient information systems, not specifically for interdisciplinary care plans. Computerized plans of care (B) may refer to electronic health records but do not necessarily imply standardized interdisciplinary plans. Student care plans (D) are educational tools for students and not typically used in case management for clients.
In planning an educational session for a patient with HIV, the nurse would include which of the following as a method of transmission for HIV? i.Saliva iv.Semen ii.Tears v.Blood iii.Breast milk
- A. 1, 4, 2005
- B. 1, 2, 4, 5
- C. 3, 4, 2005
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: 3, 4, 2005. HIV can be transmitted through breast milk, blood, and semen due to the presence of the virus in these bodily fluids. Saliva, tears, and other body fluids do not typically contain enough of the virus to transmit HIV. Therefore, choices A, B, and D are incorrect as they include saliva, tears, and other non-transmissible fluids. It is crucial for the nurse to educate the patient on the modes of transmission to prevent the spread of HIV.
A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?
- A. Deficient fluid volume related to osmotic diuresis
- B. Decreased cardiac output related to increased heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.
A client was brought to the emergency room with complains of difficulty of breathing. What can lead the nurse to suspect that the client is experiencing acute respiratory distress syndrome (ARDS)?
- A. paO2 of 95, pCO2 of 43, x-ray showing enlarged heart, bradycardia
- B. Thick green sputum production, paO2 of 74, pH of 7.41
- C. restlessness, suprasternal retractions, paO2 of 62
- D. wheezes, slow, deep respirations, pCO2 of 52, pH of 7.35
Correct Answer: C
Rationale: Step-by-step rationale for choice C being correct:
1. Restlessness: Indicates increased work of breathing and hypoxia.
2. Suprasternal retractions: Sign of respiratory distress.
3. paO2 of 62: Indicates severe hypoxemia, common in ARDS.
Summary:
A: Enlarged heart on x-ray does not directly indicate ARDS.
B: Thick green sputum suggests infection, not specific to ARDS.
D: Wheezes and slow respirations are not typical of ARDS, and pCO2 is normal in ARDS.
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. Soap can irritate the skin and exacerbate the risk for impaired skin integrity in a client receiving radiation therapy. By avoiding soap, we minimize the risk of skin breakdown and promote skin healing.
B: Applying talcum powder can actually worsen skin irritation and should be avoided.
C: Wearing a lead apron is not relevant to the nursing diagnosis of risk for impaired skin integrity.
D: Removing thoracic skin markings is not necessary for skin integrity and may disrupt the treatment plan.