Nokea
Within 20 minutes of the start of transfusion, the client develops a sudden fever. What is the nurse’s first action?
- A. Force fluids
- B. Increase the flow rate of IV fluids
- C. Continue to monitor the vitals signs
- D. Stop the transfusion
Correct Answer: D
Rationale: The correct answer is D: Stop the transfusion. This is the first action the nurse should take because the sudden fever could indicate a transfusion reaction. Stopping the transfusion is crucial to prevent further complications. Continuing to monitor vital signs (choice C) may delay necessary intervention. Forcing fluids (choice A) could worsen the situation if it is a reaction to the transfusion. Increasing the flow rate of IV fluids (choice B) is not indicated as the priority is to stop the transfusion to prevent a potential adverse event.
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A patient asks how to avoid lung cancer. The following are risk factors, except:
- A. Exposure to passive smoke
- B. Crowded living conditions
- C. Air pollution
- D. Diet low in fruits and vegetables
Correct Answer: B
Rationale: Step 1: Crowded living conditions do not directly increase the risk of lung cancer.
Step 2: Passive smoke (choice A) and air pollution (choice C) contain carcinogens linked to lung cancer.
Step 3: Diet low in fruits and vegetables (choice D) may lead to poor immune function, potentially impacting cancer risk.
Step 4: In summary, crowded living conditions do not contribute to lung cancer risk compared to the other choices.
Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?
- A. How do I best cluster these data and cues to identify problems?
- B. What problems require my immediate attention or that of the team?
- C. What major defining characteristics are present for a nursing diagnosis?
- D. How do I document care accurately and legally?
Correct Answer: B
Rationale: The correct answer is B because during outcome identification and planning, it is crucial to prioritize problems that require immediate attention to ensure patient safety and well-being. By asking what problems need immediate attention, nurses can focus on addressing urgent issues first. Choice A focuses on data clustering for problem identification, choice C is related to defining characteristics for nursing diagnoses, and choice D pertains to documentation, which are important but not directly related to prioritizing immediate problems.
Toni’s disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Bowel management
- C. Sexual activity
- D. . All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Involvement of the sacral plexus can affect bladder control, leading to bladder problems. It can also impact bowel function, requiring bowel management. Additionally, the sacral plexus plays a role in sexual function, so assessment should include sexual activity. Therefore, all options are relevant when assessing a disease process involving the sacral plexus. Other choices are incorrect as they do not cover the comprehensive assessment needed for this specific condition.
The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
- A. Begin a program of aggressive, strict mouth care
- B. Avoid traumatic injuries and exposure to any infection
- C. increase oral fluid intake to a minimum of 3000 ml daily
- D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B
Rationale: The correct answer is B - Avoid traumatic injuries and exposure to any infection. For a client with pancytopenia caused by chemotherapy, their immune system is compromised, making them more susceptible to infections and bleeding. By avoiding traumatic injuries and exposure to infections, the client can reduce the risk of complications. Option A is incorrect because aggressive mouth care may further damage the already compromised oral mucosa. Option C is incorrect because excessive fluid intake may not be necessary and could worsen electrolyte imbalances. Option D is incorrect because muscle cramps and tingling sensations are not directly related to the main concern of infection and bleeding in pancytopenia.
Which food is recommended for the patient who must increase intake of potassium?
- A. Bread
- B. Potato
- C. Egg
- D. Cereal
Correct Answer: B
Rationale: The correct answer is B: Potato. Potatoes are high in potassium, which is essential for various bodily functions. Potatoes can help increase potassium intake in patients who require it. Bread, eggs, and cereal are not as rich in potassium as potatoes. Increasing intake of these foods won't provide the necessary boost in potassium levels needed for the patient.