170 Nurse Zone Medical-surgical Nursing Application Exam Part 2 (1 To 25)
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What do you know about Medical-Surgical Nursing? Can you attempt these "170 Nurse Zone Application Exam Part 2 questions and answers?" Give it a try and check your knowledge. Nurse Zoneis a nursing specialty area in the United States and beyond that deals with the care of adult patients. If you wish to work for the same health sector, the quiz will be your best practice material. Please make sure to read all the questions carefully before attempting. All the questions are designed to enhance your knowledge and make you think! So, play it out and enhance your knowledge. Good Read moreLuck!
Questions and Answers
- 1.
SITUATION: Half of all leukemias are classified as acute. The rapid onset and progression of disease result in 100% mortality within days to months without appropriate therapy A nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support the diagnosis of acute leukemia is the existence of a large number of immature:
- A.
Lymphocytes
- B.
Thrombocytes
- C.
Reticulocytes
- D.
Leukocytes
Correct Answer
D. LeukocytesExplanation
The finding of a large number of immature leukocytes in the bone marrow biopsy would strongly support the diagnosis of acute leukemia. Leukocytes are white blood cells, and an increased number of immature leukocytes indicates abnormal cell proliferation and maturation, which is characteristic of acute leukemia. Lymphocytes, thrombocytes, and reticulocytes are not specific to leukemia and would not provide as strong of evidence for the diagnosis.Rate this question:
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- 2.
SITUATION: Half of all leukemias are classified as acute. The rapid onset and progression of disease result in 100% mortality within days to months without appropriate therapy The client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the client to:
- A.
Lie supine with his neck extended
- B.
Sit upright, leaning slightly forward
- C.
Blow his nose and then put lateral pressure on his nose
- D.
Hold his nose while bending forward at the waist
Correct Answer
B. Sit upright, leaning slightly forwardExplanation
Sitting upright, leaning slightly forward is the correct instruction for a client with epistaxis (nosebleed) caused by thrombocytopenia. This position helps to minimize the risk of blood flowing down the throat and potentially causing choking or aspiration. It also helps to reduce the amount of blood that may flow into the nasal passages, making it easier to control the bleeding. Lying supine with the neck extended or bending forward at the waist can increase the risk of blood flowing into the throat. Blowing the nose or putting lateral pressure on the nose can aggravate the bleeding.Rate this question:
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- 3.
SITUATION: Half of all leukemias are classified as acute. The rapid onset and progression of disease result in 100% mortality within days to months without appropriate therapy The nurse is teaching a client about risk factors associated with leukemia. The client needs further teaching if he states:
- A.
“History of leukemia within our family increases my risk of having leukemia”
- B.
“When I’m exposed to too much radiation leukemia could develop”
- C.
“Down’s syndrome, Fanconi’s aplastic anemia, Bloom’s syndrome are some of congenital abnormalities that increases my risk of developing leukemia”
- D.
“Leukemia is triggered by toxic substances that stimulate enhanced cell mediated immune process”
Correct Answer
D. “Leukemia is triggered by toxic substances that stimulate enhanced cell mediated immune process”Explanation
The client needs further teaching if he states that "Leukemia is triggered by toxic substances that stimulate enhanced cell mediated immune process." This statement is incorrect because leukemia is not triggered by toxic substances that stimulate an enhanced cell-mediated immune process. Leukemia is a cancer of the blood and bone marrow, and its causes are not fully understood. While exposure to certain chemicals and radiation may increase the risk of developing leukemia, it is not triggered by toxic substances that stimulate an enhanced immune process.Rate this question:
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- 4.
SITUATION: Half of all leukemias are classified as acute. The rapid onset and progression of disease result in 100% mortality within days to months without appropriate therapy A patient is undergoing bone marrow transplantation of the sternum. How will the nurse position the patient on the operating table?
- A.
Reverse Trendelenburg
- B.
Lateral or supine
- C.
Supine
- D.
Jack knife
Correct Answer
C. SupineExplanation
Supine position is the correct answer for positioning a patient undergoing bone marrow transplantation of the sternum on the operating table. The supine position refers to lying face up, with the back and palms facing upward. This position allows for easy access to the sternum for the procedure and ensures the patient's comfort and safety during the surgery.Rate this question:
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- 5.
SITUATION: Half of all leukemias are classified as acute. The rapid onset and progression of disease result in 100% mortality within days to months without appropriate therapy The nurse caring for the post bone marrow transplant understands that she should be alert for which signs and symptoms of graft-versus-host disease?
- A.
Difficulty of breathing, cyanosis, increase in body temperature
- B.
Erythematosus rash on palms, soles, ears and trunk
- C.
Bulimia, severe abdominal pain, constipation
- D.
Sudden drop of vital signs and loss of consciousness
Correct Answer
B. Erythematosus rash on palms, soles, ears and trunkExplanation
Graft-versus-host disease (GVHD) is a complication that can occur after a bone marrow transplant, where the donor's immune cells attack the recipient's tissues. One of the common signs and symptoms of GVHD is an erythematosus rash on the palms, soles, ears, and trunk. This rash is a result of inflammation and immune response in the skin. Therefore, the nurse should be alert for this specific symptom to identify and manage GVHD in post bone marrow transplant patients.Rate this question:
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- 6.
SITUATION: Anemia may be due to acute or chronic blood loss. Increased destruction of RBCs can result from extrinsic sources, antibodies as in transfusion mismatch or from infectious agents and toxins Which step should be done first when administering a blood transfusion?
- A.
Verify the blood product and client identity
- B.
Verify the physician’s order
- C.
Verify the client identity and blood product with another nurse
- D.
Assess the IV site
Correct Answer
B. Verify the physician’s orderExplanation
Before administering a blood transfusion, it is important to verify the physician's order. This ensures that the blood transfusion is necessary and appropriate for the client. The other steps mentioned, such as verifying the blood product and client identity, and assessing the IV site, are also important but should be done after verifying the physician's order.Rate this question:
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- 7.
SITUATION: Anemia may be due to acute or chronic blood loss. Increased destruction of RBCs can result from extrinsic sources, antibodies as in transfusion mismatch or from infectious agents and toxins A 70 year old client’s hematocrit and hemoglobin were 32.1% and 11.5% respectively. Based on these results, the most appropriate nursing intervention should be to:
- A.
Conduct a complete nutritional assessment of the client
- B.
Advise the client to have the test repeated in three months
- C.
Nothing because these are expected values for this age
- D.
Understand that mild anemia is an expected response to the aging process
Correct Answer
A. Conduct a complete nutritional assessment of the clientExplanation
Conducting a complete nutritional assessment of the client is the most appropriate nursing intervention based on the client's hematocrit and hemoglobin levels. These levels indicate anemia, which can be caused by a deficiency in essential nutrients such as iron, vitamin B12, or folate. By conducting a nutritional assessment, the nurse can identify any deficiencies and develop a plan to address them, such as recommending dietary changes or supplements. Advising the client to have the test repeated in three months or doing nothing because these values are expected for their age would not address the underlying cause of the anemia. Mild anemia is not an expected response to the aging process, so this option is also not appropriate.Rate this question:
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- 8.
SITUATION: Anemia may be due to acute or chronic blood loss. Increased destruction of RBCs can result from extrinsic sources, antibodies as in transfusion mismatch or from infectious agents and toxins A physician has ordered a transfusion of whole blood for a client who had repair of a dissecting abdominal aortic aneurysm. What action should the nurse take after the transfusion has been initiated?
- A.
Check the client’s vital signs every half hour
- B.
Add the total number of milliliters transfused to the intake and output
- C.
Discontinue the primary IV of dextrose
- D.
Stay with the client for 15 minutes to assess for any reactions
Correct Answer
D. Stay with the client for 15 minutes to assess for any reactionsExplanation
After initiating the transfusion of whole blood, the nurse should stay with the client for 15 minutes to assess for any reactions. This is important because transfusion reactions can occur, and immediate assessment is necessary to identify and manage any adverse reactions. Checking vital signs every half hour is not sufficient for timely detection of reactions. Adding the total number of milliliters transfused to the intake and output is not directly related to monitoring for transfusion reactions. Discontinuing the primary IV of dextrose is not necessary unless there is a specific indication to do so.Rate this question:
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- 9.
SITUATION: Anemia may be due to acute or chronic blood loss. Increased destruction of RBCs can result from extrinsic sources, antibodies as in transfusion mismatch or from infectious agents and toxins If a client who is receiving a blood transfusion experiences an acute hemolytic reaction, which nursing intervention is the most important?
- A.
Immediately stop the transfusion, infuse dextrose 5% in water, and call the physician
- B.
Slow the transfusion and monitor the client closely
- C.
Stop the infusion, notify the blood bank, and administer antihistamines
- D.
Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician
Correct Answer
D. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physicianExplanation
If a client who is receiving a blood transfusion experiences an acute hemolytic reaction, the most important nursing intervention is to immediately stop the transfusion to prevent further complications. Infusing normal saline solution helps to maintain the client's fluid balance and stabilize their blood pressure. Notifying the blood bank is crucial for further investigation and ensuring patient safety. Lastly, calling the physician is necessary to report the reaction and seek further medical guidance.Rate this question:
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- 10.
SITUATION: Anemia may be due to acute or chronic blood loss. Increased destruction of RBCs can result from extrinsic sources, antibodies as in transfusion mismatch or from infectious agents and toxins Four days after receiving 2 units of whole blood the patient exhibits anemia, and yellowish skin and sclera. Coomb’s test was positive. Fluid support was the management given to this patient. What type of blood transfusion reaction transpired?
- A.
Acute hemolytic reaction
- B.
Septic reaction
- C.
Delayed hemolytic reaction
- D.
Simple allergic reaction
Correct Answer
C. Delayed hemolytic reactionExplanation
The patient's symptoms of anemia, yellowish skin and sclera, and a positive Coomb's test indicate that the patient is experiencing a delayed hemolytic reaction. This type of reaction occurs when antibodies in the recipient's blood destroy the transfused red blood cells. Fluid support is given to manage the patient's symptoms.Rate this question:
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- 11.
SITUATION: As health care providers, nurses deal with allergic conditions far more than might be suspected. Allergic rhinitis, asthma, and dermatitis are just a few examples of these immunologic diseases The nurse is aware that nutritional support of a client’s natural defense mechanisms would indicate the need for a diet high in:
- A.
The essential fatty acids
- B.
Dietary cellulose and fiber
- C.
The amino acid, tryptophan
- D.
Vitamins A, C, E and selenium
Correct Answer
D. Vitamins A, C, E and seleniumExplanation
Vitamins A, C, E, and selenium are known to support and enhance the body's natural defense mechanisms. These vitamins and minerals have antioxidant properties that help protect the body against free radicals and oxidative stress, which can weaken the immune system. Therefore, a diet high in these nutrients would provide the necessary support for the client's natural defense mechanisms.Rate this question:
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- 12.
SITUATION: As health care providers, nurses deal with allergic conditions far more than might be suspected. Allergic rhinitis, asthma, and dermatitis are just a few examples of these immunologic diseases A nurse does a PPD on a client suspected with pulmonary tuberculosis. After 5 to 8 minutes the nurse interprets the test results. Erythema with wheal formation less than 3 mm appeared. She documented this as a negative result. Did the nurse observe the correct steps and interpretation of the skin test?
- A.
Yes, the procedure was done properly and the result is accurate
- B.
No, the result must be read 48 to 72 hours after the skin test to obtain an accurate result
- C.
No, erythema with wheal formation less than 3 mm denotes a positive result
- D.
No, the result is inconclusive
Correct Answer
B. No, the result must be read 48 to 72 hours after the skin test to obtain an accurate resultExplanation
The nurse did not observe the correct steps and interpretation of the skin test. The result must be read 48 to 72 hours after the skin test to obtain an accurate result. Therefore, the nurse's interpretation of the test result as negative after only 5 to 8 minutes is incorrect.Rate this question:
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- 13.
SITUATION: As health care providers, nurses deal with allergic conditions far more than might be suspected. Allergic rhinitis, asthma, and dermatitis are just a few examples of these immunologic diseases Mrs. Macaroon came in to the out-patient department complaining about runny nose, tearing of the eyes, and sneezing episodes. She reported that she has been busy supervising the renovation of their house. Loratadine (Claritin) was prescribed for her allergic rhinitis. Which statement when made by the client indicates understanding of the teaching regarding this medication?
- A.
“This is an antihistamine, that’s why I’ll expect drowsiness with this medication”
- B.
“This steroid nasal spray would be very useful in treating my allergy, it does not evoke a lot of side effects”
- C.
“This Aerosol medication should have been started a week before the renovation to make it more effective, so I should expect immediate relief of my allergy”
- D.
“This antihistamine, will not cause drowsiness. I’m happy I could still supervise the carpenters”
Correct Answer
D. “This antihistamine, will not cause drowsiness. I’m happy I could still supervise the carpenters”Explanation
The correct answer indicates that the client understands the teaching regarding the medication. It shows that the client knows that the antihistamine prescribed, loratadine (Claritin), will not cause drowsiness. This is important because drowsiness is a common side effect of many antihistamines, but loratadine is known to have a lower incidence of causing drowsiness. The client's statement also demonstrates that she is happy she can still supervise the carpenters, indicating that she is aware of the potential side effects and is relieved that drowsiness will not be an issue for her.Rate this question:
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- 14.
SITUATION: As health care providers, nurses deal with allergic conditions far more than might be suspected. Allergic rhinitis, asthma, and dermatitis are just a few examples of these immunologic diseases The key nursing diagnosis for the client with hypersensitivity disorders is:
- A.
Altered health maintenance related to lack of knowledge of disease process, treatment regimen and risk control methods
- B.
Knowledge deficit; health promotion related to lack of informative sources regarding hypersensitivity disorders
- C.
Risk for illness or injury related to unawareness of risk control methods
- D.
Impaired psychosocial adjustment related to lack of health promotion behaviors
Correct Answer
A. Altered health maintenance related to lack of knowledge of disease process, treatment regimen and risk control methodsExplanation
The correct answer is "Altered health maintenance related to lack of knowledge of disease process, treatment regimen and risk control methods." This nursing diagnosis is appropriate because it addresses the client's lack of knowledge about their hypersensitivity disorder, which can affect their ability to properly maintain their health. By identifying this diagnosis, the nurse can develop a care plan that includes education and support to help the client understand their disease process, treatment options, and methods to control their symptoms and reduce risk. This will ultimately improve the client's ability to manage their condition effectively.Rate this question:
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- 15.
SITUATION: As health care providers, nurses deal with allergic conditions far more than might be suspected. Allergic rhinitis, asthma, and dermatitis are just a few examples of these immunologic diseases A one year old male was brought to the outpatient department due to red, pruritic rashes on the cheeks and forehead. After consultation with the pediatrician, the nurse makes her home instructions which include all of the following. Select all that apply: 1. Use gentle soaps; 2. Instruct parent to keep fingernails of her child trimmed; 3. Bathe the child in a cool water to soothe itching; 4. Apply petroleum jelly to affected areas after bathing
- A.
1 and 4
- B.
1, 3 and 4
- C.
1, 2 and 4
- D.
1, 2, 3, and 4
Correct Answer
C. 1, 2 and 4Explanation
The correct answer is 1, 2 and 4.
The nurse's home instructions for the child with red, pruritic rashes on the cheeks and forehead include using gentle soaps (1) to avoid further irritation, instructing the parent to keep the child's fingernails trimmed (2) to prevent scratching and causing more damage to the skin, and applying petroleum jelly to affected areas after bathing (4) to help soothe and moisturize the skin. Bathing the child in cool water (3) may provide temporary relief from itching, but it is not mentioned in the given instructions. Therefore, the correct options are 1, 2 and 4.Rate this question:
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- 16.
SITUATION: A female client, aged 79 years, is admitted to the hospital with a diagnosis of bacterial pneumonia. She has a temperature of 106°F, is diaphoretic, has a productive cough, and is experiencing moderate shortness of breath When obtaining the client’s health history, the nurse learns that she has long-standing osteoarthritis, follows a vegetarian diet, has never been seriously ill, and is very concerned with cleanliness. The client says, “I hope I can take a bath each day. I feel so dirty if I don’t bathe every day.” Which of the following factors would add most to the danger posed by her illness?
- A.
The client’s age
- B.
History of osteoarthritis
- C.
Following a vegetarian diet
- D.
Bathing daily in cold water
Correct Answer
A. The client’s ageExplanation
The client's age is the factor that would add most to the danger posed by her illness. As an older adult, her immune system may not be as strong, making her more susceptible to infections. Additionally, her age may make it more difficult for her body to fight off the bacterial pneumonia.Rate this question:
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- 17.
SITUATION: A female client, aged 79 years, is admitted to the hospital with a diagnosis of bacterial pneumonia. She has a temperature of 106°F, is diaphoretic, has a productive cough, and is experiencing moderate shortness of breath A priority nursing diagnosis for this hospitalized client with bacterial pneumonia and shortness of breath would be:
- A.
Altered cardiopulmonary tissue perfusion related to myocardial damage
- B.
Potential self-care deficit related to fatigue
- C.
Fluid volume deficit related to nausea and vomiting
- D.
Altered thought processes related to inadequate pain relief
Correct Answer
B. Potential self-care deficit related to fatigueExplanation
The priority nursing diagnosis for this client would be "Potential self-care deficit related to fatigue." This is because the client is experiencing moderate shortness of breath, which can lead to fatigue and difficulty performing self-care activities. The other options are not as relevant to the client's current condition.Rate this question:
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- 18.
SITUATION: A female client, aged 79 years, is admitted to the hospital with a diagnosis of bacterial pneumonia. She has a temperature of 106°F, is diaphoretic, has a productive cough, and is experiencing moderate shortness of breath Considering the client’s symptoms and condition, the nurse should include which of the following measures in the plan of care?
- A.
Position changes every 4 hours
- B.
Nasotracheal suctioning to clear secretions
- C.
Frequent linen changes
- D.
Frequent offering of a bedpan
Correct Answer
C. Frequent linen changesExplanation
Frequent linen changes should be included in the plan of care for this client because she is diaphoretic, which means she is sweating excessively. Sweating can cause the linens to become damp and uncomfortable for the client, increasing the risk of skin breakdown and infection. Therefore, frequent linen changes are necessary to maintain the client's comfort and hygiene.Rate this question:
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- 19.
SITUATION: A female client, aged 79 years, is admitted to the hospital with a diagnosis of bacterial pneumonia. She has a temperature of 106°F, is diaphoretic, has a productive cough, and is experiencing moderate shortness of breath For the client with a productive cough and difficulty breathing, the nurse should obtain the body temperature at what site?
- A.
Mouth
- B.
Groin fold
- C.
Rectum
- D.
Axillae
Correct Answer
C. RectumExplanation
The nurse should obtain the body temperature at the rectum because the client is experiencing a productive cough and difficulty breathing. Rectal temperature is considered the most accurate method for measuring body temperature in critically ill patients. It provides a more reliable reading than oral, axillary, or groin fold measurements.Rate this question:
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- 20.
SITUATION: A female client, aged 79 years, is admitted to the hospital with a diagnosis of bacterial pneumonia. She has a temperature of 106°F, is diaphoretic, has a productive cough, and is experiencing moderate shortness of breath A client with bacterial pneumonia is coughing up tenacious, purulent sputum. Which of the following measures would most likely help liquefy these viscous secretions?
- A.
Performing postural drainage
- B.
Breathing humidified air
- C.
Clapping and percussing over the affected lung
- D.
Performing coughing and deep-breathing exercises
Correct Answer
B. Breathing humidified airExplanation
Breathing humidified air would most likely help liquefy the viscous secretions in a client with bacterial pneumonia. Humidified air can help to moisten and thin the secretions, making it easier for the client to cough them up. This can help to clear the airways and improve breathing. Other measures such as postural drainage, clapping and percussing, and coughing and deep-breathing exercises may also be beneficial in promoting the clearance of secretions, but breathing humidified air specifically targets the viscosity of the secretions.Rate this question:
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- 21.
SITUATION: Mrs. Romero, an elderly tube-fed resident from a nursing home is admitted with recent changes in level of consciousness. Her skin and mouth are very dry, and her urine is scant and dark yellow. Laboratory assessment reveals sodium, 150 mEq/dl; chloride, 106 mEq/dl; BUN, 25 mg/dl; and creatinine, 1.2 What do these assessment findings suggest?
- A.
Hypovolemic hyponatremia
- B.
Hypovolemic hypernatremia
- C.
Hypervolemic hypernatremia
- D.
Hypervolemic hyponatremia
Correct Answer
B. Hypovolemic hypernatremiaExplanation
The assessment findings of dry skin, dry mouth, scant and dark yellow urine, and elevated sodium levels suggest hypovolemic hypernatremia. Hypovolemic refers to a decrease in blood volume, which can lead to dehydration. Hypernatremia refers to an elevated sodium level in the blood. This combination suggests that Mrs. Romero is dehydrated and experiencing an imbalance in her body's water and sodium levels.Rate this question:
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- 22.
SITUATION: Mrs. Romero, an elderly tube-fed resident from a nursing home is admitted with recent changes in level of consciousness. Her skin and mouth are very dry, and her urine is scant and dark yellow. Laboratory assessment reveals sodium, 150 mEq/dl; chloride, 106 mEq/dl; BUN, 25 mg/dl; and creatinine, 1.2 What precautions will be needed to prevent further fluid and electrolyte shifts? Select all that apply: 1. Monitor client for response to IV fluid replacement of hypoosmolar electrolyte solutions; 2. Monitor patient for absence of clinical manifestations of hypernatremia and return to normal sodium levels; 3. Prevent osmotic dieresis from D5W by maintaining the prescribed rate; 4. Use IV pumps in high risk patients; 5. Initiate safety and seizure precautions if the patient manifests weakness or cerebral changes; 6. Offer water and fluids every 2 to 3 hours
- A.
All except 4
- B.
All except 1
- C.
All except 6
- D.
All of the above
Correct Answer
C. All except 6Explanation
To prevent further fluid and electrolyte shifts in the elderly tube-fed resident, several precautions need to be taken. Monitoring the client's response to IV fluid replacement of hypoosmolar electrolyte solutions (option 1) is important to ensure that the fluid and electrolyte balance is being restored effectively. Similarly, monitoring the patient for absence of clinical manifestations of hypernatremia and return to normal sodium levels (option 2) is necessary to ensure that the electrolyte levels are within the normal range. Preventing osmotic diuresis from D5W by maintaining the prescribed rate (option 3) helps to prevent excessive fluid loss. Initiating safety and seizure precautions if the patient manifests weakness or cerebral changes (option 5) is important to ensure the safety of the patient. Therefore, all options except option 6 are needed to prevent further fluid and electrolyte shifts.Rate this question:
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- 23.
SITUATION: Mrs. Romero, an elderly tube-fed resident from a nursing home is admitted with recent changes in level of consciousness. Her skin and mouth are very dry, and her urine is scant and dark yellow. Laboratory assessment reveals sodium, 150 mEq/dl; chloride, 106 mEq/dl; BUN, 25 mg/dl; and creatinine, 1.2 The nurse notes that the blood urea nitrogen (BUN) is 25 mg/dl. Which of the following diseases can be a result of increased BUN?
- A.
Renal insufficiency
- B.
Rhabdomyolysis
- C.
End stage renal disease
- D.
Glomerulonephritis
Correct Answer
A. Renal insufficiencyExplanation
Renal insufficiency can be a result of increased BUN. BUN is a waste product that is filtered out of the blood by the kidneys. When the kidneys are not functioning properly, they are unable to effectively filter out BUN, leading to an increase in its levels in the blood. This can be indicative of renal insufficiency, which is a condition where the kidneys are not able to adequately perform their function of filtering waste products from the blood. This can result in various symptoms and complications, including changes in level of consciousness and dry skin and mouth, as seen in the given situation.Rate this question:
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- 24.
SITUATION: Mrs. Romero, an elderly tube-fed resident from a nursing home is admitted with recent changes in level of consciousness. Her skin and mouth are very dry, and her urine is scant and dark yellow. Laboratory assessment reveals sodium, 150 mEq/dl; chloride, 106 mEq/dl; BUN, 25 mg/dl; and creatinine, 1.2 One of nurse Julie’s diagnosis of the patient is altered oral mucous membranes related to lack of body water secondary to hypernatremia. Which of the following outcomes is the most appropriate?
- A.
Moist oral mucous membrane maintained
- B.
No occurrence of further deterioration of the oral mucous membranes and moist oral mucous membranes maintained
- C.
Oral fluid intake initiated every hour
- D.
Decreased thirst
Correct Answer
B. No occurrence of further deterioration of the oral mucous membranes and moist oral mucous membranes maintainedExplanation
The most appropriate outcome is "No occurrence of further deterioration of the oral mucous membranes and moist oral mucous membranes maintained." This outcome aligns with the nurse's diagnosis of altered oral mucous membranes related to lack of body water secondary to hypernatremia. By maintaining moist oral mucous membranes, the nurse can prevent further deterioration and promote the patient's overall oral health.Rate this question:
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- 25.
SITUATION: Mrs. Romero, an elderly tube-fed resident from a nursing home is admitted with recent changes in level of consciousness. Her skin and mouth are very dry, and her urine is scant and dark yellow. Laboratory assessment reveals sodium, 150 mEq/dl; chloride, 106 mEq/dl; BUN, 25 mg/dl; and creatinine, 1.2 Mrs. Romero’s family calls and wants to know “if she will make it?”’ How would the nurse respond?
- A.
“Mrs. Romero has already been stabilized; you might want to come see her”
- B.
“Mrs. Romero needs you; it is better that you come by”
- C.
“I am not allowed to provide any information over the phone… it is better for you to visit her”
- D.
“I am not allowed to discuss this matter with you, please wait while I call the attending physician”
Correct Answer
C. “I am not allowed to provide any information over the phone… it is better for you to visit her”Explanation
The nurse would respond by saying, "I am not allowed to provide any information over the phone... it is better for you to visit her." This response indicates that the nurse cannot give any updates or prognosis over the phone and suggests that it would be beneficial for the family to visit Mrs. Romero in person.Rate this question:
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