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| Section | Weight | Objectives |
|---|---|---|
| Psychosocial Integrity | 6–12% | - Behavioral Interventions - Therapeutic Communication - Chemical Dependency and Substance Use Disorders - Family Dynamics - Mental Health Concepts - Grief and Loss - End-of-Life Support - Coping Mechanisms |
| Physiological Integrity | 43–67% | - Pharmacological and Parenteral Therapies
|
| Health Promotion and Maintenance | 6–12% | - Aging Process - Developmental Stages and Transitions - Self-Care - Physical Assessment Techniques - Antepartum, Intrapartum, Postpartum and Newborn Care - Disease Prevention and Health Screening - Health Promotion Programs |
| Safe and Effective Care Environment | 26–38% | - Safety and Infection Control
|
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NEW QUESTION # 792
A complication for which the nurse should be alert following a liver biopsy is:
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver.
NEW QUESTION # 793
On the third postpartum day, the nurse would expect the lochia to be:
Answer: B
Explanation:
Explanation
(A) This discharge occurs from delivery through the 3rd day. There is dark red blood, placental debris, and clots. (B) This discharge occurs from days 4-10. The lochia is brownish, serous, and thin. (C) This discharge occurs from day 10 through the 6thweek. The lochia is yellowish white. (D) This is not a classification of lochia but relates to the amount of discharge.
NEW QUESTION # 794
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. (B) This range is the amount of drainage after the first
24 hours postoperatively. During the first 24 hours, it is 300-500 mL. (C) During the first 24 hours after surgery, this range is the expected amount of drainage. (D) The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mLshould be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.
NEW QUESTION # 795
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
NEW QUESTION # 796
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
Answer: C
Explanation:
Explanation
(A) The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. (B) This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. (C) The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. (D) Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.
NEW QUESTION # 797
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