Nokea
Wilma knew that James have an adequate respiratory condition if she notices that
- A. James’ respiratory rate is 18
- B. James’ Oxygen saturation is 91%
- C. There are frank blood suction from the tube
- D. There are moderate amount of tracheobronchial secretions
Correct Answer: A
Rationale: The correct answer is A because a normal respiratory rate for an adult is typically between 12-20 breaths per minute. A respiratory rate of 18 falls within this range, indicating adequate respiratory function.
Choice B is incorrect because an oxygen saturation of 91% is below the normal range of 95-100%, suggesting potential respiratory insufficiency.
Choice C is incorrect as frank blood suction from the tube indicates a serious issue such as bleeding, not adequate respiratory condition.
Choice D is also incorrect as the presence of a moderate amount of tracheobronchial secretions may indicate a respiratory infection or other respiratory issue, not necessarily adequate respiratory condition.
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A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. This type of diagnosis focuses on improving the client's well-being and maximizing their health potential. By adding Readiness for enhanced urinary elimination to the care plan, the nurse acknowledges the patient's willingness to learn self-catheterization, which aligns with health promotion. Other choices are incorrect because: A (Risk) implies potential harm, B (Problem focused) focuses on current issues, and D (Collaborative problem) involves multiple healthcare providers working together on a specific problem.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale:
1. Asking about chief concerns helps to focus the interview on the patient's needs.
2. It demonstrates active listening and empathy.
3. Allows the nurse to prioritize issues and provide appropriate care.
4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition.
Incorrect choices:
A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it.
B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed.
D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
- A. Keep eyes closed
- B. Wear sunglasses
- C. Do not drive for 8 hours
- D. Avoid caffeinated beverages
Correct Answer: B
Rationale: The correct answer is B: Wear sunglasses. Dilated pupils are sensitive to light, so wearing sunglasses can help protect the eyes from excessive light exposure. Keeping the eyes closed (A) may provide temporary relief but does not protect the eyes from light. Avoiding driving for 8 hours (C) is important after certain eye procedures but not specifically related to dilated pupils. Avoiding caffeinated beverages (D) is unrelated to pupil dilation.
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
- A. Sleep with the head of the bed slightly
- B. Use a soft toothbrush and electric razor
- C. Drink citrus juices frequently for nourishment
- D. Increase his activity level and ambulates frequently
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because:
A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression.
C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding.
D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.