1.
The nurse has been assigned to perform colostomy care for a patient who has had a recent hemicolectomy. The nurse can best determine how the patient tolerated the procedure by:
Correct Answer
A. Noting all objective signs and symptoms during the procedure.
Explanation
The nurse can best determine how the patient tolerated the procedure by noting all objective signs and symptoms during the procedure. Objective signs and symptoms are measurable and observable indicators of the patient's condition. By closely monitoring the patient's vital signs, pain level, wound appearance, and any other physical changes or discomfort during the procedure, the nurse can assess the patient's response and overall tolerance to the colostomy care. This information will help the nurse make appropriate adjustments to the care plan and ensure the patient's well-being.
2.
The chief reason that the nurse explains procedure steps and purpose to the patient prior to performing a treatment is:
Correct Answer
B. Patient anxiety is decreased with understanding.
Explanation
Explaining the procedure steps and purpose to the patient prior to performing a treatment helps to decrease patient anxiety. When patients understand what will happen during the procedure and why it is being done, they feel more informed and in control, which reduces their anxiety. This can also improve patient cooperation and compliance with the treatment. Additionally, by explaining the procedure to the patient, the nurse can address any concerns or questions the patient may have, further alleviating anxiety and promoting a positive patient experience.
3.
When preparing to administer oxygen via nasal cannula, the nurse attaches the oxygen flowmeter to a container of sterile distilled water to:
Correct Answer
D. Prevent drying the patient's nasopHaryngeal mucosa.
Explanation
Attaching the oxygen flowmeter to a container of sterile distilled water helps to prevent drying of the patient's nasopharyngeal mucosa. Oxygen therapy can cause dryness and irritation in the respiratory tract, and humidification can help alleviate these symptoms. By passing the oxygen through the sterile distilled water, the nurse adds moisture to the oxygen before it reaches the patient's nasal cannula, preventing the drying of the mucosa and improving patient comfort.
4.
While continuing to plan the diet for the pregnant female, the nurse advises the patient to increase the calories in her diet by:
Correct Answer
A. 300 calories/day
Explanation
The nurse advises the patient to increase her daily calorie intake by 300 calories. This is because during pregnancy, the body requires additional energy to support the growth and development of the fetus. However, it is important to note that the increase in calorie intake should be gradual and not excessive, as excessive weight gain during pregnancy can lead to complications. Increasing the calorie intake by 300 calories per day is a safe and appropriate recommendation to ensure the mother and baby receive adequate nutrition.
5.
The nutritional requirements of older adults differ from those of younger people. In particular, they will require:
Correct Answer
B. Fewer Calories
Explanation
As people age, their metabolism tends to slow down, resulting in a decrease in energy expenditure. Therefore, older adults require fewer calories to maintain their weight and overall health. This is because their bodies have a reduced need for energy due to a decrease in physical activity and muscle mass. Consuming fewer calories helps prevent weight gain and obesity, which are common concerns in older adults. It is important for older adults to focus on nutrient-dense foods to meet their nutritional needs while consuming fewer calories.
6.
According to the food pyramid, milk primarily supplies which nutrients?
Correct Answer
B. Calcuim and protein
Explanation
According to the food pyramid, milk primarily supplies calcium and protein. Calcium is essential for the development and maintenance of strong bones and teeth, while protein is important for growth, repair, and maintenance of body tissues. Milk is a good source of both these nutrients, making it an important part of a balanced diet.
7.
Which of the followng statement about diabetes mellitus and diet are correct?
Correct Answer
A. "Include high-fiber foods in menu planning"
Explanation
Including high-fiber foods in menu planning is a correct statement about diabetes mellitus and diet. High-fiber foods help regulate blood sugar levels, improve digestion, and promote overall health. They are recommended for individuals with diabetes as they have a lower glycemic index and can help control blood sugar spikes. High-fiber foods include fruits, vegetables, whole grains, legumes, and nuts.
8.
Two days following a myocardial infarction, a client has a temperature of 100.2 F. The nurse should:
Correct Answer
D. Record the temperature and monitor vital signs at routine intervals
Explanation
The client's temperature of 100.2 F is only slightly elevated and may be a normal response to the recent myocardial infarction. It is important to record the temperature and continue monitoring vital signs at routine intervals to assess for any further changes or signs of infection. This is the appropriate action as the temperature is not significantly high and does not warrant immediate notification of the physician or specific interventions such as auscultating for diminished breath sounds or encouraging deep breathing and coughing.
9.
The patient develops a small pressure ulcer on the sacral area. The nurse should plan to deal with this problem by:
Correct Answer
A. Keeping the area dry
Explanation
Keeping the area dry is the correct answer because moisture can further irritate and worsen pressure ulcers. By keeping the area dry, the nurse can promote healing and prevent infection. Moisture can create a breeding ground for bacteria and can also soften the skin, making it more susceptible to damage. Therefore, keeping the area dry is an important step in managing pressure ulcers and promoting healing.
10.
The nurse is teaching a client how to use the call bell system. Which level of Maslow's Hierarchy of needs does this nursing action address?
Correct Answer
A. Safety
Explanation
This nursing action addresses the level of Safety in Maslow's Hierarchy of needs. Teaching the client how to use the call bell system ensures that they have a means of getting help in case of emergencies or when they need assistance. This promotes their sense of safety and security, which is a fundamental need according to Maslow's theory.
11.
Communication is a major component of providing nursing care. The nurse understands that communication is important because it ties people to their:
Correct Answer
A. Social surroundings
Explanation
The correct answer is social surroundings because communication allows individuals to connect and interact with others in their social environment. Effective communication in nursing care helps build relationships, establish trust, and promote collaboration between healthcare providers, patients, and their families. By understanding and addressing the social context in which patients exist, nurses can better meet their needs and provide holistic care.
12.
A patient with a terminal illness reaches the stage of acceptance. The nurse can best help the client during this stage by:
Correct Answer
D. Being around though not necessarilly speaking
Explanation
During the stage of acceptance, a patient with a terminal illness may experience a range of emotions and may not always want to talk or be comforted. By being around the client without necessarily speaking, the nurse can provide a sense of presence and support. This allows the patient to feel that they are not alone and provides them with the space and freedom to process their emotions in their own way. It respects the patient's need for silence or solitude while still offering a comforting presence.
13.
Which finding best suggests that nursing interventions for the patient with an excess fluid volume have been effective?
Correct Answer
A. Clear breath sounds
Explanation
Clear breath sounds suggest that nursing interventions for the patient with excess fluid volume have been effective because excess fluid in the body can lead to fluid accumulation in the lungs, causing crackles or wheezing. Clear breath sounds indicate that the lungs are free from fluid congestion, indicating that the interventions have helped to remove excess fluid and improve respiratory function.
14.
The nurse assesses a client's electrolyte levels. Which electrolyte of intracellular fluid does the nurse identify as most important?
Correct Answer
D. Potassium
Explanation
Potassium is the most important electrolyte of intracellular fluid because it plays a crucial role in maintaining the cell's electrical potential and regulating cellular functions. It is responsible for muscle contraction, nerve impulse transmission, and maintaining the balance of fluids and electrolytes within the cell. Potassium also helps in regulating the heart rhythm and blood pressure. Imbalances in potassium levels can lead to serious health complications, such as muscle weakness, irregular heartbeat, and even cardiac arrest. Therefore, monitoring and maintaining adequate potassium levels is essential for overall cellular health and functioning.