Nokea
Which of the following is more life threatening?
- A. BP=180/100
- B. BP=160/120
- C. BP=90/60
- D. BP=80/50
Correct Answer: D
Rationale: BP 80/50 is most life-threatening e.g., hypoperfusion risks failure vs. 180/100 (hypertension), 160/120 (severe), 90/60 (borderline). Nurses prioritize this e.g., fluids for stability, per hemodynamics.
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The nurse is teaching a client who underwent a hypophysectomy for hypopituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.
- A. Nose blowing
- B. Teeth brushing
- C. Bending forward
- D. Lying in a semi-Fowler's position
Correct Answer: A
Rationale: Post-hypophysectomy, nose blowing (A) risks CSF leak or meningitis by disrupting the surgical site. Brushing (B) and semi-Fowler's (D) are safe. Bending (C) is risky but less immediate. A is correct. Rationale: Nasal pressure can breach the pituitary fossa repair, a critical complication in early recovery, per post-operative neurosurgery care, unlike benign actions.
The nurse recorded Mr. Gary's vitals in his chart. This is an example of?
- A. Documentation
- B. Standard precautions
- C. Health policy
- D. Patient education
Correct Answer: A
Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.
When recording blood pressure, the sounds which can be heard with a stethoscope placed over the artery is termed as:
- A. Wheeze
- B. Murmurs
- C. Crackle sounds
- D. Korotkoff sounds
Correct Answer: D
Rationale: Blood pressure measurement involves listening to arterial sounds via a stethoscope as the cuff deflates. These sounds, known as Korotkoff sounds, occur in five phases, starting with a tapping (systolic pressure) and fading to silence (diastolic pressure). Wheezes are respiratory sounds, murmurs relate to heart valves, and crackles indicate lung fluid none apply to blood pressure. Named after Nikolai Korotkoff, these sounds are a cornerstone of manual blood pressure assessment, ensuring accurate readings essential for diagnosing hypertension or hypotension, reflecting cardiovascular health.
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- A. Orange juice
- B. Water only
- C. Milk
- D. Apple juice
Correct Answer: A
Rationale: Orange juice enhances iron absorption in iron-deficiency anemia via vitamin C, reducing ferric to ferrous form for better uptake a proven dietary aid. Milk inhibits it, water or apple juice lack this boost. Nurses teach this pairing, improving hemoglobin levels, optimizing therapy for fatigue and pallor relief.
Which of the following statement best describe autonomy?
- A. Doing good for the client
- B. Fairness and equality
- C. Respecting client's decision
- D. Keeping promises
Correct Answer: C
Rationale: Autonomy is respecting client decisions (C), per ethics self-determination (e.g., refusing care). Doing good (A) is beneficence, fairness (B) justice, promises (D) fidelity. C best defines autonomy's focus, making it correct.