In planning the nursing care for this patient what is the important nursing intervention a nurse must do?

Correct Answer: C

Rationale: Assessing the patient for respiratory distress is the important nursing intervention that must be done in this situation. The scenario provided indicates that the patient with chronic obstructive pulmonary disease (COPD) is experiencing increased work of breathing, which puts them at risk for respiratory distress. It is crucial for the nurse to monitor the patient's respiratory status closely, including assessing their oxygen saturations, respiratory rate, and effort, to identify any signs of respiratory distress early and intervene promptly. This proactive assessment can help prevent further deterioration of the patient's condition and ensure appropriate nursing interventions are implemented promptly.

Correct Answer: D

Rationale: Multiple myeloma is a plasma cell neoplasm characterized by the presence of abnormal monoclonal plasma cells in the bone marrow, which produce a monoclonal spike on serum protein electrophoresis. The clinical presentation of weakness, bone pain, and recurrent infections is typical of multiple myeloma. Anemia can result from bone marrow infiltration by the abnormal plasma cells, hypercalcemia is due to bone destruction and release of calcium, renal insufficiency can result from hypercalcemia and protein deposition in the kidneys, and the monoclonal spike in serum protein electrophoresis indicates the presence of a monoclonal protein. Waldenström macroglobulinemia, Hodgkin lymphoma, and chronic lymphocytic leukemia do not typically present with the classic tetrad of findings seen in multiple myeloma.

Correct Answer: C

Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.

Correct Answer: C

Rationale: Bruxism is the dental condition characterized by the involuntary grinding or clenching of teeth, often occurring during sleep. This habitual behavior can lead to tooth wear, muscle pain, headaches, and temporomandibular joint dysfunction. Dental caries (choice A) refers to tooth decay, while attrition (choice B) specifically refers to the wearing down of teeth due to forces like chewing. Periodontitis (choice D) is a condition involving inflammation and infection of the gums and supporting structures of the teeth. Among the choices provided, bruxism is the most fitting description for the condition characterized by tooth grinding and clenching.

Correct Answer: C

Rationale: Assessing the patient's airway is the first priority when admitting injured patients. A clear airway is crucial for effective breathing. If the airway is obstructed, the patient will not be able to breathe properly, leading to serious consequences. Therefore, ensuring a patent airway takes precedence over assessing breathing, circulation, or vital signs. Once the airway is secured, the emergency team can proceed with assessing breathing, circulation, and vital signs in order to provide appropriate treatment and care.