Nokea
A client is brought to the emergency department in an unconscious condition. The client’s wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?
- A. Client’s wife
- B. Medical documents
- C. Test results
- D. Assessment data
Correct Answer: A
Rationale: The correct answer is A: Client’s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (B), test results (C), and assessment data (D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.
You may also like to solve these questions
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
- A. Yearly after age 40
- B. After the birth of the first child and every 2 years thereafter
- C. After the first menstrual period and annually thereafter
- D. Every 3 years between ages 20 and 40 and annually thereafter
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. The American Cancer Society recommends yearly mammograms after age 40 for early breast cancer detection.
2. Mammograms are most effective for women aged 40 and older in detecting breast cancer.
3. Regular mammograms can help detect breast cancer at an early stage, improving treatment outcomes.
Summary of why other choices are incorrect:
B: Mammograms should start at age 40, not after the birth of the first child.
C: Mammograms are not recommended after the first menstrual period; they should start at age 40.
D: Mammograms should be done annually after age 40, not every 3 years between ages 20 and 40.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise the collaborative problem part of the diagnostic statement because "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate" is a nursing diagnosis, not a collaborative problem. Collaborative problems involve issues that require both nursing and medical interventions, whereas nursing diagnoses focus on the nurse's role in addressing the patient's health issues. Therefore, the nurse should revise the collaborative problem part to accurately reflect the collaborative aspect of the patient's care. Etiology (A), nursing diagnosis (B), and defining characteristic (D) are not the parts of the diagnostic statement that need revision in this scenario.
A patient is being given Digoxin to treat heart failure. Which of the ff. is a usual adult daily dosage of digoxin (Lanoxin)?
- A. 0.005 mg
- B. 0.025 mg
- C. 0.25 mg
- D. 2.5 mg
Correct Answer: C
Rationale: Rationale:
C: 0.25 mg is the correct daily dosage of Digoxin for adults with heart failure. This dosage is within the usual range of 0.125-0.25 mg. It helps improve heart function and manage heart failure symptoms.
A: 0.005 mg is too low and ineffective.
B: 0.025 mg is also too low for therapeutic effect.
D: 2.5 mg is too high and may lead to toxicity in most adult patients.
How many drops per minute should be delivered?
- A. 6
- B. 17
- C. 50
- D. 100
Correct Answer: B
Rationale: The correct answer is B: 17 drops per minute. To calculate the correct drip rate, you need to use the formula: (Volume to be infused in mL / Time in minutes) x Drop factor. In this case, if the volume to be infused is 100 mL and the time is 60 minutes with a drop factor of 20, the calculation would be: (100 / 60) x 20 = 33.33 drops per minute. Since we cannot deliver fractional drops, the closest whole number is 17 drops per minute. This ensures the correct delivery rate for the medication.
Choice A (6 drops per minute) is incorrect as it would be too slow and may not deliver the medication effectively. Choice C (50 drops per minute) and Choice D (100 drops per minute) are incorrect as they would both deliver the medication too quickly, potentially causing harm to the patient. The correct answer, 17 drops per minute, ensures a safe and accurate delivery rate
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect. The anesthesiologist should monitor the client for this adverse reaction. Muscle rigidity and spasms are common with ketamine administration and can affect the client's comfort and safety during the procedure. It is important for the nurse to promptly address any signs of muscle rigidity or spasms to prevent complications.
Summary of why other choices are incorrect:
B: Hiccups - Ketamine can cause hiccups, but it is not the primary side effect to monitor for in this scenario.
C: Extrapyramidal reactions - Ketamine does not typically cause extrapyramidal reactions.
D: Respiratory depression - Ketamine is known for its minimal effect on respiratory depression compared to other anesthetics. Monitoring respiratory depression is still important, but not the primary concern with ketamine administration in this case.