Nokea
10. Priority Decision: A bedridden patient tells the nurse she has low back pain and asks if the area could be massaged. What is the best action by the nurse?
- A. Ask the patient if she has ever tried acupuncture for back pain.
- B. Explain to the patient that massage may be done only by a licensed therapist and offer a PRN analgesic instead.
- C. Comfortably position the patient to expose the area and massage the back with effleurage and petrissage strokes.
- D. Call the physical therapy department to request that a physical therapist see the patient to provide a therapeutic massage.
Correct Answer: C
Rationale: Providing a gentle massage using effleurage and petrissage strokes (option C) is within the scope of nursing practice and can provide immediate relief to the patient.
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Sue is having a minor procedure performed. Which type of anesthesia is most likely to be used?
- A. General.
- B. Epidural.
- C. Regional.
- D. Conscious sedation.
Correct Answer: D
Rationale: Conscious sedation is often used for minor procedures.
Which member of the surgical team does not scrub into the operating room?
- A. The surgeon.
- B. The circulating nurse.
- C. The scrub nurse or surgical tech.
- D. The holding area nurse.
Correct Answer: B
Rationale: The circulating nurse does not scrub into the operating room. Their role is to manage activities outside the sterile field and assist with tasks such as retrieving supplies and documenting care.
The nurse knows that a patient taught sleep hygiene practices needs further instruction when he says
- A. Once I go to bed, I should get up if I am not asleep after 20 minutes.
- B. It’s okay to have my usual two glasses of wine in the evening before bed.
- C. A couple of crackers with cheese and a glass of milk may help to relax before bed.
- D. I should go to the gym earlier in the day so that I’m done at least 6 hours before bedtime.
Correct Answer: B
Rationale: The correct answer is B. Alcohol disrupts sleep architecture, making it counterproductive for sleep hygiene. Getting up after 20 minutes (A) is a recommended practice, and exercising early (D) promotes better sleep.
A patient is admitted to the ER and presents as very talkative, highly alert, pupil dilated, has a relatively high temperature and is sweating. He or she tells you he or she never needs to sleep anymore. What would you suspect is causing the patient's condition?
- A. The patient is under the influence of heroin.
- B. The patient is under the influence of amphetamines.
- C. The patient is under the influence of oxycodone.
- D. The patient is under the influence of Oxycodan.
Correct Answer: B
Rationale: Symptoms such as talkativeness, alertness, dilated pupils, and hyperthermia are characteristic of amphetamine use.
A client calls to report redness to the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first?
- A. Please call your doctor.'
- B. Apply a cool compress to your eyes.'
- C. If you are wearing contact lenses, remove them.'
- D. Take an over-the-counter antihistamine.'
Correct Answer: C
Rationale: Removing contact lenses is the first step to prevent further irritation and allow proper assessment of the eye condition.