A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?

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Question 1 of 9

A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?

Correct Answer: A

Rationale: The correct answer is A: Ineffective Airway Clearance. In a patient with AIDS and PCP, maintaining clear airways is crucial to prevent respiratory distress and hypoxia. Pneumocystis pneumonia can cause thick secretions and mucus plugging, leading to difficulty breathing. Ensuring effective airway clearance is a priority to optimize oxygenation and prevent respiratory complications. Impaired oral mucous membranes (B) and imbalanced nutrition (C) are important considerations but not as immediate as airway clearance. Activity intolerance (D) may be a concern for the patient but ensuring adequate oxygenation takes precedence.

Question 2 of 9

A nurse in a long-term care setting that is fundedby Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

Correct Answer: A

Rationale: The correct answer is A: A minimum data set. In a long-term care setting funded by Medicare and Medicaid, completing standardized protocols for assessment and care planning for reimbursement involves using a minimum data set, which is a standardized instrument for assessing residents' health status. This set of data elements is necessary for comprehensive assessment and care planning to ensure appropriate reimbursement. The other choices (B, C, D) do not specifically address the standardized protocols required for reimbursement in this setting. An admission assessment and acuity level would be part of the process, but not the primary task being completed in this scenario. A focused assessment on a specific body system or an intake assessment form and auditing phase are not synonymous with the standardized protocols needed for reimbursement in a Medicare/Medicaid-funded long-term care facility.

Question 3 of 9

The nurse in an allergy clinic is educating a new patient about the pathology of the patients health problem. What response should the nurse describe as a possible consequence of histamine release?

Correct Answer: B

Rationale: The correct answer is B: Contraction of bronchial smooth muscle. Histamine release can lead to bronchoconstriction, which narrows the airways and causes difficulty in breathing. This is a common symptom in allergic reactions like asthma. Constriction of small venules (Choice A) is not a typical consequence of histamine release. Dilation of large blood vessels (Choice C) is more associated with histamine's role in increasing vascular permeability. Decreased secretions from gastric and mucosal cells (Choice D) is not directly related to histamine's effects on smooth muscle contraction.

Question 4 of 9

Which types of nurses make the best communicatorswith patients?

Correct Answer: B

Rationale: The correct answer is B: Those who develop critical thinking skills. Critical thinking skills enable nurses to assess situations, analyze information, and communicate effectively with patients. By using critical thinking, nurses can tailor their communication style to each patient's needs, leading to better understanding and rapport. A: Learning effective psychomotor skills is important but does not directly correlate with being a good communicator. C: Liking different kinds of people is beneficial for interpersonal relationships, but it does not necessarily make one a better communicator. D: Maintaining perceptual biases hinders effective communication as it can lead to misunderstandings and barriers in the communication process.

Question 5 of 9

Which of the following nurses actions carries the greatest potential to prevent hearing loss due to ototoxicity?

Correct Answer: D

Rationale: The correct answer is D because being aware of patients' medication regimens allows nurses to identify and monitor ototoxic medications that can cause hearing loss. By collaborating with other professionals, nurses can adjust medications or recommend alternative treatments to prevent or minimize ototoxicity. This proactive approach directly targets the root cause of potential hearing loss. A: Understanding types of hearing loss is important but does not directly prevent ototoxicity. B: Educating about age-related changes in hearing does not address ototoxicity prevention. C: Educating about noise exposure risks is important for overall hearing health but does not specifically prevent ototoxicity.

Question 6 of 9

The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?

Correct Answer: D

Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.

Question 7 of 9

A nurse is teaching the staff about informatics.Which information from the staff indicates the nurse needs to follow up?

Correct Answer: C

Rationale: The correct answer is C. Computer competency does not equate to informatics competency. Informatics involves more than just basic computer skills; it encompasses the ability to use technology to manage and analyze data for improved healthcare outcomes. A: This is a correct statement about informatics proficiency. B: This is also a correct statement about the skills needed for informatics. D: This is a true statement about nursing informatics being a recognized specialty, but it does not indicate a need for follow-up. In summary, choice C is incorrect as it oversimplifies the concept of informatics, while choices A, B, and D provide accurate information related to informatics.

Question 8 of 9

Spontaneous termination of a pregnancy is considered to be an abortion if

Correct Answer: A

Rationale: The correct answer is A because spontaneous termination of a pregnancy is considered an abortion if it occurs before 20 weeks gestation. This is based on the medical definition of abortion as the termination of a pregnancy before the fetus is able to survive outside the womb. Choices B, C, and D are incorrect as they do not accurately reflect the criteria for defining abortion. B and D are specific conditions related to the fetus and the presence of infection, while C refers to passing products of conception intact, which can happen in both spontaneous and induced abortions.

Question 9 of 9

A nurse is caring for an immigrant with low income.Which information should the nurse consider when planning care for this patient?

Correct Answer: B

Rationale: The correct answer is B: There is an increased incidence of disease. Low-income immigrants often face barriers to healthcare access, leading to higher rates of undiagnosed and untreated health conditions. This information is crucial for the nurse to plan appropriate care interventions. Incorrect choices: A: Decreased frequency of morbidity is not accurate as low-income immigrants may experience higher rates of illness due to lack of resources. C: Increased level of health is unlikely in this population due to socioeconomic factors affecting health outcomes. D: Decreased mortality rate is not supported as low-income immigrants may have higher mortality rates due to limited access to healthcare.

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