The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)

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Question 1 of 9

The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)

Correct Answer: A

Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.

Question 2 of 9

The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?

Correct Answer: D

Rationale: When caring for a patient receiving total parenteral nutrition (TPN), it is crucial to maintain strict aseptic technique to prevent infection. Wearing a sterile mask when changing the central venous catheter dressing helps to reduce the risk of introducing pathogens into the catheter site, which can lead to serious bloodstream infections. It is essential to use sterile gloves, a sterile mask, and to assess the insertion site for any signs or symptoms of infection during central venous catheter dressing changes. Additionally, to prevent infection, TPN infusion tubing should be changed every 24 hours, and no single container of TPN should be hung for longer than 24 hours, with lipids not running for longer than 12 hours.

Question 3 of 9

The nurse caring for a patient diagnosed with Parkinsons disease has prepared a plan of care that would include what goal?

Correct Answer: A

Rationale: Patients diagnosed with Parkinson's disease often experience speech and communication difficulties due to the effects of the disease on the muscles involved in speech production. This can manifest as soft, slurred speech or difficulty articulating words. Therefore, promoting effective communication would be an essential goal in the plan of care for a patient with Parkinson's disease. This goal may involve strategies such as speech therapy, communication devices, or providing a conducive environment to facilitate clearer communication between the patient and healthcare providers. By focusing on promoting effective communication, the nurse can help improve the patient's quality of life and enhance their ability to express their needs and concerns.

Question 4 of 9

Draw up prescribed amount of sterile solution ordered.

Correct Answer: D

Rationale: The correct sequence for drawing up a prescribed amount of sterile solution ordered is as follows: 6, 5, 1, 3, 2, 4.

Question 5 of 9

A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene?

Correct Answer: D

Rationale: Mashed potatoes and gravy are not appropriate for a full liquid diet. A full liquid diet consists of foods that are liquid at room temperature or melt into liquid form at body temperature. Mashed potatoes and gravy are not in liquid form and therefore should not be consumed by a patient following a full liquid diet. The nurse should intervene and provide education about the correct food choices allowed on a full liquid diet, such as custard, frozen yogurt, and pureed vegetables.

Question 6 of 9

A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action?

Correct Answer: D

Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.

Question 7 of 9

The patient hasH. pylori. Which action shouldthe nurse take?

Correct Answer: C

Rationale: The most appropriate action for a patient with H. pylori is to encourage completion of antibiotic therapy. H. pylori is a bacterium that causes peptic ulcers, and treatment involves a combination of antibiotics to eradicate the infection. Antibiotic therapy is crucial in eliminating the bacteria and preventing complications such as recurrent ulcers or stomach cancer. Therefore, the nurse should prioritize ensuring that the patient completes the prescribed course of antibiotics to effectively treat the H. pylori infection.

Question 8 of 9

A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?

Correct Answer: A

Rationale: The most appropriate nursing intervention for a patient with AIDS experiencing extreme anxiety is to teach the patient guided imagery. Guided imagery is a relaxation technique that can help the patient reduce anxiety levels, promote a sense of calm, and improve overall well-being. By teaching the patient how to use guided imagery, the nurse empowers the patient to manage her anxiety in a non-pharmacological way. This intervention promotes self-care and allows the patient to have a tool to use independently beyond the hospital setting. Giving the patient more control of her antiretroviral regimen may be beneficial for adherence but does not directly address the anxiety symptoms. Increasing the patient's activity level may be helpful for overall well-being but may not specifically target the extreme anxiety. Collaborating with the patient's physician to obtain an order for hydromorphone, a potent opioid medication, is not appropriate unless it is indicated for severe pain management, not anxiety.

Question 9 of 9

The nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that he effects of neoplasms are caused by the compression and infiltration of normal tissue. The physiologic changes that result can cause what pathophysiologic events? Select all that apply.

Correct Answer: A

Rationale: Neoplasms can cause pathophysiologic events such as intracranial hemorrhage and increased intracranial pressure (ICP) due to expansion of the mass within the confined space of the skull. Intracranial hemorrhage can occur as the neoplasm damages blood vessels in the brain or causes them to become more fragile. Increased ICP can result from the growing mass causing compression of surrounding structures and obstructing the flow of cerebrospinal fluid, leading to symptoms such as headaches, nausea, vomiting, and changes in mental status.

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