Nokea
A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?
- A. Check the patient's chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screening on the patient.
- D. Request the physician on-call to assess the patient.
Correct Answer: B
Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.
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A nurse reviewed the arterial blood gas reading of a 25-year-old male. The nurse should be able to conclude the patient is experiencing which of the following conditions?
- A. metabolic acidosis
- B. respiratory acidosis
- C. metabolic alkalosis
- D. respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is respiratory alkalosis. In respiratory alkalosis, there is an elevated pH and low carbon dioxide levels (PaCO2 < 35 mmHg). In the given arterial blood gas reading, the patient's pH is 7.41 (within normal range), PaCO2 is 29 mmHg (below normal range), indicating respiratory alkalosis. The bicarbonate level is normal (25 mEq/l), ruling out metabolic acidosis or alkalosis. The low PaO2 (54 mmHg) may indicate hypoxemia, but it is not directly related to the acid-base disorder being assessed. Metabolic acidosis (choice A) is characterized by low pH and low bicarbonate levels, which are not present in this case. Respiratory acidosis (choice B) is indicated by low pH and high PaCO2 levels, which also do not match the provided data. Metabolic alkalosis (choice C) is defined by high pH and high bicarbonate levels, which are not seen in this scenario.
A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?
- A. Notify the doctor
- B. Empty the drain
- C. Do nothing
- D. Remove the drain
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.
In Parkinson's disease, a client's difficulty in performing voluntary movements is known as:
- A. Akinesia.
- B. Dyskinesia.
- C. Chorea.
- D. Dystonia.
Correct Answer: C.
Rationale: In Parkinson's disease, the client's difficulty in performing voluntary movements is termed dyskinesia. Dyskinesia refers to the impairment of the ability to execute voluntary muscle movements. Akinesia, on the other hand, refers to the absence or lack of voluntary movement. Chorea is characterized by involuntary, rapid, irregular movements. Dystonia involves sustained muscle contractions resulting in abnormal postures or twisting movements. Therefore, dyskinesia is the specific term used for the described difficulty in Parkinson's disease.
A client asks a nurse working in a dental office what type of drug the dentist uses to provide anesthesia during the extraction of the client's wisdom teeth. The dentist uses an anesthetic gas, also known as laughing gas. This agent is:
- A. nitrous oxide.
- B. nitrogen.
- C. nitric oxide.
- D. nitrogen dioxide.
Correct Answer: A
Rationale: The correct answer is nitrous oxide. Nitrous oxide is commonly known as laughing gas and is used as an anesthetic gas for procedures like dental extractions. It produces analgesia and mild euphoria without loss of consciousness. Nitrogen is a nonmetallic element found in air, while nitric oxide is a vasodilator produced from L-arginine. Nitrogen dioxide is a poisonous gas found in smog and exhaust fumes and is not used for anesthesia.
A patient has experienced a severe third-degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
- A. Shock phase
- B. Emergent phase
- C. Healing phase
- D. Wound proliferation phase
Correct Answer: A
Rationale: The correct answer is A: Shock phase. The shock phase occurs within the first 24-48 hours of burn management. During this phase, the focus is on stabilization, fluid resuscitation, and monitoring for potential complications. Choice B, the Emergent phase, is incorrect as it refers to the initial phase of burn care immediately after the injury. Choice C, the Healing phase, occurs later in the treatment process when the wound starts to repair itself. Choice D, the Wound proliferation phase, is not a recognized phase in burn management.