ANSWER AND RATIONALE Show
1. D, F, G, H 2. A, B, C 3. A, B, C, E 4. A, B, D, E 5. D, B, C, A 6. C, D, A, B 7. C, D, E 8. A, B, C, D 9. A, B A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5). 10. B, C, D The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase. 11. A, B Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it. 12. A, B, C, D Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful. 13. B, D, E Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache, visual disturbances such as diplopia, blurred vision, yellow-green halos, photophobia, drowsiness, fatigue, and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. 14: B,
C, D, G 15. A, C, D 16. B, C, E, F 17. B, D, E 18. B, A, E, C, D 19. A, D, E 20. D, F, G,
H 21. A, B, C, D 22. C, A, D, B 23. A, C, D, E, B 24. A, B, E B. Laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it is absorbed. The amount of pain should be measured and documented with either a 1-10 scale or the Wong's FACES for younger children. C. A special diet is not indicated after this surgery. D. After a laparoscopic appendectomy, there is little drainage and no dressings. E. Auscultating for bowel sounds and documenting their presence or absence evaluate the child's adaptation to the intestinal trauma caused by the surgery. 25. A,B,D The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night is not indicative of impaired respiratory health. Which action should the nurse take in the event of an accidental poisoning?Remove any visible materials from areas such as the mouth and eyes to terminate exposure to the poison(s). Identify the type and amount of substance ingested, if possible. This may help to detemine the required antidote. Call your local poison control centre before attempting any interventions.
Which activity is performed by the nurse can improve patient safety?Educating patients on their post-discharge care is a simple, yet effective, example of how nurses can improve patient safety. By working with patients to ensure they have a thorough understanding of their medical condition and self-care routine before they are discharged, nurses help facilitate a smooth recovery.
Which of the following measures is most appropriate for a nurse to take to prevent injury in a patient who is confused?If the client is confused, the least intrusive method of restraint is the use of a bed alarm such as the Bed-Check bed exit alarm device.
Which should the nurse include when teaching a client with C diff about decreasing the risk of transmission to family members?Clean their hands with soap and water or an alcohol-based hand rub before and after caring for every patient. This can prevent C. diff and other germs from being passed from one patient to another on their hands.
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