Eight months after the delivery of her first child, a 31-yr-old woman is seeking care for
occasional incontinence when sneezing or laughing. Which intervention should the
nurse recommend first?
-Kegel exercises
-Use of adult incontinence pads
-Intermittent self-catheterization
-Dietary changes including fluid restriction
Give this one a try later!
, -Kegel exercises
Rationale:
Patients who have stress incontinence frequently benefit from Kegel
exercises (pelvic floor muscle exercises). The use of incontinence pads
does not resolve the problem, and intermittent self-catheterization would
be a premature recommendation. Dietary changes are not likely to
influence the patient's urinary continence.
A patient with a 25-year history of type 1 diabetes is reporting fatigue, edema, and an
irregular heartbeat. On assessment, the nurse notes newly developed hypertension
and uncontrolled blood glucose levels. Which diagnostic study is most indicative of
chronic kidney disease (CKD)?
-Serum creatinine
-Serum potassium
-Microalbuminuria
-Calculated glomerular filtration rate (GFR)
Give this one a try later!
-Calculated glomerular filtration rate (GFR)
Rationale:
The best study to determine kidney function or CKD that would be
expected in the patient with diabetes is the calculated GFR that is obtained
from the patient's age, gender, race, and serum creatinine. It would need to
be abnormal for 3 months to establish a diagnosis of CKD. A creatinine
clearance test done with a blood sample and a 24-hour urine collection is
also important. Serum creatinine is not the best test for CKD because the
level varies with different patients. Serum potassium levels could explain
why the patient has an irregular heartbeat. The finding of microalbuminuria
can alert the patient with diabetes about potential renal involvement and
potentially failing kidneys. However, urine albumin levels are not used for
diagnosis of CKD.
,Ten days after receiving a bone marrow transplant, a patient develops a skin rash on
the palms, soles of feet, jaundice, and diarrhea. What does the nurse determine these
clinical manifestations are indicating?
-The patient is experiencing a type I allergic reaction.
-An atopic reaction is causing the patient's symptoms.
-The patient is experiencing rejection of the bone marrow.
-Cells in the transplanted bone marrow are attacking the host tissue.
Give this one a try later!
-Cells in the transplanted bone marrow are attacking the host tissue.
Rationale:
The patient's symptoms are characteristic of graft-versus-host-disease
(GVHD) in which transplanted cells mount an immune response to the
host's tissue. The target organs for the GVHD phenomenon are the skin,
liver, and GI tract. GVHD is not a type I allergic response or an atopic
reaction, and it differs from transplant rejection in that the graft rejects the
host rather than the host rejecting the graft.
The nurse should administer an as-needed dose of magnesium citrate after noting
what information when reviewing a patient's medical record?
-Abdominal pain and bloating
-No bowel movement for 3 days
-A decrease in appetite by 50% over 24 hours
-Muscle tremors and other signs of hypomagnesemia
Give this one a try later!
, -No bowel movement for 3 days
Rationale:
Magnesium citrate is an osmotic laxative that produces a soft, semisolid
stool usually within 15 minutes to 3 hours. This medication would benefit the
patient who has not had a bowel movement for 3 days. It would not be
given for abdominal pain and bloating, decreased appetite, or signs of
hypomagnesemia.
What should the nurse teach the patients in the assisted living facility to decrease their
risk for antibiotic-resistant infection? (Select all that apply.)?
-Wash hands frequently.
-Take antibiotics as prescribed.
-Take the antibiotic until it is gone.
-Take antibiotics to prevent illnesses like colds.
-Save leftover antibiotics to take if needed later.
Give this one a try later!
-Wash hands frequently.
-Take antibiotics as prescribed.
-Take the antibiotic until it is gone.
Rationale:
To decrease the risk for antibiotic-resistant infections, people should wash
their hands frequently, follow the directions when taking the antibiotics,
finish the antibiotic, do not request antibiotics for colds or flu, do not save
leftover antibiotics, or take antibiotics to prevent an illness without them
being prescribed by a health care provider.
A patient after a stroke who primarily uses a wheelchair for mobility has developed
diarrhea with fecal incontinence. What is a priority assessment by the nurse?
-Fecal impaction
-Perineal hygiene
occasional incontinence when sneezing or laughing. Which intervention should the
nurse recommend first?
-Kegel exercises
-Use of adult incontinence pads
-Intermittent self-catheterization
-Dietary changes including fluid restriction
Give this one a try later!
, -Kegel exercises
Rationale:
Patients who have stress incontinence frequently benefit from Kegel
exercises (pelvic floor muscle exercises). The use of incontinence pads
does not resolve the problem, and intermittent self-catheterization would
be a premature recommendation. Dietary changes are not likely to
influence the patient's urinary continence.
A patient with a 25-year history of type 1 diabetes is reporting fatigue, edema, and an
irregular heartbeat. On assessment, the nurse notes newly developed hypertension
and uncontrolled blood glucose levels. Which diagnostic study is most indicative of
chronic kidney disease (CKD)?
-Serum creatinine
-Serum potassium
-Microalbuminuria
-Calculated glomerular filtration rate (GFR)
Give this one a try later!
-Calculated glomerular filtration rate (GFR)
Rationale:
The best study to determine kidney function or CKD that would be
expected in the patient with diabetes is the calculated GFR that is obtained
from the patient's age, gender, race, and serum creatinine. It would need to
be abnormal for 3 months to establish a diagnosis of CKD. A creatinine
clearance test done with a blood sample and a 24-hour urine collection is
also important. Serum creatinine is not the best test for CKD because the
level varies with different patients. Serum potassium levels could explain
why the patient has an irregular heartbeat. The finding of microalbuminuria
can alert the patient with diabetes about potential renal involvement and
potentially failing kidneys. However, urine albumin levels are not used for
diagnosis of CKD.
,Ten days after receiving a bone marrow transplant, a patient develops a skin rash on
the palms, soles of feet, jaundice, and diarrhea. What does the nurse determine these
clinical manifestations are indicating?
-The patient is experiencing a type I allergic reaction.
-An atopic reaction is causing the patient's symptoms.
-The patient is experiencing rejection of the bone marrow.
-Cells in the transplanted bone marrow are attacking the host tissue.
Give this one a try later!
-Cells in the transplanted bone marrow are attacking the host tissue.
Rationale:
The patient's symptoms are characteristic of graft-versus-host-disease
(GVHD) in which transplanted cells mount an immune response to the
host's tissue. The target organs for the GVHD phenomenon are the skin,
liver, and GI tract. GVHD is not a type I allergic response or an atopic
reaction, and it differs from transplant rejection in that the graft rejects the
host rather than the host rejecting the graft.
The nurse should administer an as-needed dose of magnesium citrate after noting
what information when reviewing a patient's medical record?
-Abdominal pain and bloating
-No bowel movement for 3 days
-A decrease in appetite by 50% over 24 hours
-Muscle tremors and other signs of hypomagnesemia
Give this one a try later!
, -No bowel movement for 3 days
Rationale:
Magnesium citrate is an osmotic laxative that produces a soft, semisolid
stool usually within 15 minutes to 3 hours. This medication would benefit the
patient who has not had a bowel movement for 3 days. It would not be
given for abdominal pain and bloating, decreased appetite, or signs of
hypomagnesemia.
What should the nurse teach the patients in the assisted living facility to decrease their
risk for antibiotic-resistant infection? (Select all that apply.)?
-Wash hands frequently.
-Take antibiotics as prescribed.
-Take the antibiotic until it is gone.
-Take antibiotics to prevent illnesses like colds.
-Save leftover antibiotics to take if needed later.
Give this one a try later!
-Wash hands frequently.
-Take antibiotics as prescribed.
-Take the antibiotic until it is gone.
Rationale:
To decrease the risk for antibiotic-resistant infections, people should wash
their hands frequently, follow the directions when taking the antibiotics,
finish the antibiotic, do not request antibiotics for colds or flu, do not save
leftover antibiotics, or take antibiotics to prevent an illness without them
being prescribed by a health care provider.
A patient after a stroke who primarily uses a wheelchair for mobility has developed
diarrhea with fecal incontinence. What is a priority assessment by the nurse?
-Fecal impaction
-Perineal hygiene
