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Why are older adults with heart and blood vessel diseases susceptible to thrombophlebitis?
- A. Choose all that apply
- B. IV drugs and chemicals
- C. Impaired mobility
- D. Compromised circulation
Correct Answer: B
Rationale: The correct answer is B: IV drugs and chemicals. Thrombophlebitis is inflammation of a vein with blood clot formation, commonly caused by irritants like IV drugs. Impaired mobility (C) and compromised circulation (D) are risk factors for thrombophlebitis, but not specific to older adults with heart and blood vessel diseases. A is incorrect as not all choices apply in this scenario.
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Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
- A. Shrimp and tomatoes
- B. Cheese and bananas
- C. Lobster and squash
- D. Lamb and peaches
Correct Answer: D
Rationale: The correct answer is D (Lamb and peaches) because lamb is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Peaches are high in vitamin C, which enhances iron absorption. Shrimp and tomatoes (A) have some iron but are not as rich in iron as lamb. Cheese and bananas (B) are not significant sources of iron. Lobster and squash (C) also do not provide as much iron as lamb. Overall, the combination of heme iron from lamb and vitamin C from peaches makes them the most suitable choices for an anemic client requiring iron therapy.
Why should the nurse closely monitor older adults when they are receiving IV therapy? Choose all that apply
- A. Because their defense mechanisms are less efficient
- B. Because they are prone to fluid overload
- C. Because they are prone to reduced renal efficiency
- D. Because they have inadequate intake of dietary fiber
Correct Answer: E
Rationale: The correct answer is not provided in the choices. However, if I were to choose from the given options, the most appropriate would be C: "Because they are prone to reduced renal efficiency." This is important because older adults may have decreased kidney function, leading to potential complications with IV therapy. Option A is incorrect as defense mechanisms are not directly related to monitoring IV therapy. Option B is incorrect as fluid overload is a general concern with IV therapy regardless of age. Option D is irrelevant to the need for monitoring IV therapy in older adults.
A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? “Evaluative measures are multiple-page documents used to evaluate nurse
- A. performance.” NursingStoreRN “Evaluative measures include assessment data used to determine whether patients
- B. have met their expected outcomes and goals.” “Evaluative measures are used by quality assurance nurses to determine the progress
- C. a nurse is making from novice to expert nurse.”
- D. “Evaluative measures are objective views for completion of nursing interventions.”
Correct Answer: B
Rationale: The correct answer is B because evaluative measures in nursing refer to the assessment data used to determine if patients have achieved their expected outcomes and goals. This is crucial in evaluating the effectiveness of the care provided.
Choice A is incorrect because it defines evaluative measures as multiple-page documents, which is not accurate. Choice C is incorrect as it focuses on the progression of a nurse's skill level rather than patient outcomes. Choice D is incorrect as it defines evaluative measures as objective views of completing nursing interventions, which is too narrow of a definition.
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
- A. Gordon’s Functional Health Patterns
- B. Activity-exercise pattern assessment
- C. General to specific assessment
- D. Problem-oriented assessment
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing, which is a general observation, before moving on to more specific details. This approach allows the nurse to gather comprehensive information systematically.
A: Gordon’s Functional Health Patterns involves assessing a patient's health across several categories, not specifically related to wound care.
B: Activity-exercise pattern assessment focuses on the patient's physical activity and exercise routines, not the wound dressing.
D: Problem-oriented assessment involves identifying and addressing specific health issues, rather than starting with a general observation like the appearance of a surgical dressing.
Which of the following dietary interventions prevents the precipitation of calcium renal stones?
- A. High fiber diet
- B. Increased protein intake
- C. High fluid intake
- D. Intake of zinc
Correct Answer: C
Rationale: The correct answer is C: High fluid intake. Adequate hydration helps prevent calcium from becoming concentrated in the urine, reducing the risk of calcium stone formation. Increased fiber intake (choice A) may help prevent other types of stones but not specifically calcium stones. Increased protein intake (choice B) can actually increase calcium excretion, potentially increasing the risk of calcium stone formation. Zinc intake (choice D) does not directly impact calcium stone formation. In summary, high fluid intake is crucial for preventing the precipitation of calcium renal stones due to its role in diluting urine and preventing calcium concentration.