Nokea
Why would T3, T4, blood chemistry panel, and drug screen tests be performed prior to admission?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
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Total parenteral nutrition(TPN), is one of the home therapies being used for Chelsea Mann, 35, with acute ulcerative colitis causing massive diarrhea. She and her family will need instruction about:
- A. caring for the central catheter.
- B. how to mix the TPN solution.
- C. fixing malfunctions occuring in the IV pump.
- D. teaching the neighbors how to care for her.
Correct Answer: A
Rationale: Prevention of infection, and potential septicemia, is of prime importance for someone with a central catheter. Mixing TPN is a very specialized procedure, and should be done under laminar airflow by a pharmacist. IV pumps are machines that do malfunction, but the safest thing to do would be to get the manufacturer to do the repair. Having neighbors be a support to Chelsea and her family may not be possible. More information would be necessary prior to choosing this as an option for a nursing diagnosis.
Place the steps for removal of a foreign body from the ear canal in the correct order.
- A. Refer for treatment of external otitis.
- B. Inspect the tympanic membrane for trauma.
- C. Obtain history for type of object.
- D. Choose appropriate fluid for irrigation or instillation.
Correct Answer: C
Rationale: Obtaining a history helps determine the safest method for removing the foreign body and prevents further injury.
A client with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?
- A. Would you like to talk more about this?
- B. You are lucky to have such a devoted daughter.
- C. It is normal to feel as though you are a burden.
- D. Would you like to meet with the chaplain?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and empathy, encouraging the client to express their feelings further. This response shows support and openness to discuss sensitive topics, promoting therapeutic communication. Choice B fails to address the client's emotional distress directly. Choice C may invalidate the client's feelings. Choice D may not be appropriate unless the client expresses interest in meeting with the chaplain. Overall, option A is the best response for addressing the client's emotional needs effectively.
A healthcare professional is interested in making interdisciplinary work a high priority. Which actions by the professional best demonstrate this skill? (Select ONE that does not apply)
- A. Consulting with other disciplines on client care
- B. Coordinating discharge planning for home safety
- C. Participating in comprehensive client rounding
- D. Sharing the care plans with other disciplines
Correct Answer: B
Rationale: The correct answer is B because coordinating discharge planning for home safety is not directly related to interdisciplinary work. The other choices (A, C, D) involve active collaboration and communication with different disciplines to ensure comprehensive client care. Consulting with other disciplines, participating in client rounding, and sharing care plans all demonstrate a high priority on interdisciplinary work by fostering teamwork and integration of various perspectives to enhance patient outcomes. In contrast, coordinating discharge planning for home safety is more focused on individual patient needs and safety rather than interdisciplinary collaboration.
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?
- A. Assess the client's blood pressure and level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Obtain a permit for an emergency temporary pacemaker insertion.
- D. Prepare to administer antidysrhythmic medication.
Correct Answer: A
Rationale: The correct action is to assess the client's blood pressure and level of consciousness. This is crucial in a client with an inferior wall MI to monitor for potential complications like cardiogenic shock. Assessing these vital signs can provide immediate information on the client's hemodynamic stability. Calling the health care provider or Rapid Response Team may be necessary based on assessment findings. Obtaining a permit for a temporary pacemaker insertion and preparing to administer antidysrhythmic medication are not the most immediate priorities and may not address the client's current needs.