Nokea
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
- A. breath sounds
- B. blood pressure
- C. capillary refill
- D. butterfly rash
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct:
1. Blood pressure is vital in this scenario due to prednisone discontinuation.
2. Abruptly stopping prednisone can lead to adrenal insufficiency.
3. Adrenal insufficiency can cause hypotension, a life-threatening condition.
4. Monitoring blood pressure can help detect and manage potential complications.
Summary of other choices:
A: Breath sounds – Important but not the priority in this specific situation.
C: Capillary refill – Useful for assessing circulation but not urgent in this context.
D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
You may also like to solve these questions
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
- A. Stand as far away from the implant as possible and call for help.
- B. Pick up the implant with long-handled forceps and place it in a lead-lined container.
- C. Leave the room and notify the radiation therapy department immediately.
- D. Put the implant back in place, using forceps and a shield for self-protection, and call for help.
Correct Answer: D
Rationale: The correct answer is D. First, the nurse should put the implant back in place using forceps and a shield for self-protection. This is important to limit the exposure to radiation for both the client and the nurse. Second, the nurse should call for help to ensure proper handling and further assistance. Standing away from the implant (choice A) does not address the immediate need to secure the implant. Picking up the implant with long-handled forceps and placing it in a lead-lined container (choice B) should only be done by trained personnel to prevent further exposure. Leaving the room and notifying the radiation therapy department immediately (choice C) delays the immediate action needed to prevent unnecessary radiation exposure.
Which type of neuron transmits impulses from the central nervous system to the muscles and glands?
- A. Afferent
- B. Affective
- C. Efferent
- D. Effective A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET M
Correct Answer: C
Rationale: The correct answer is C: Efferent neurons transmit impulses from the central nervous system to muscles and glands. This is because efferent neurons are responsible for carrying motor signals away from the central nervous system to control muscle movement and gland secretion.
Afferent neurons (choice A) transmit sensory information from the body to the central nervous system. Affective (choice B) is not a term used in neuroscience for describing neuron functions. Effective (choice D) is not a term used in neuroscience and does not describe the specific function of transmitting impulses from the central nervous system to muscles and glands.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. During the first phase of the nursing process (assessment), the nurse collects data to establish a comprehensive database of the patient's health status. This information serves as the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities (C) in the third phase (planning), and determining outcomes achieved (D) in the fourth phase (evaluation). Completing a comprehensive database is crucial in the initial assessment phase to gather accurate information for the subsequent steps in the nursing process.
A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
- A. Indwelling urinary catheter kit
- B. Cardiac monitor
- C. Tracheostomy set
- D. Humidifier
Correct Answer: C
Rationale: Correct Answer: C - Tracheostomy set
Rationale:
1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway.
2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention.
3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment.
Summary of other choices:
A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care.
B: Cardiac monitor - Important but secondary to airway management in this situation.
D: Humidifier - Not essential for immediate post-thyroidectomy care.
A client is brought to the emergency department unconscious after a fall. What is the primary source of information in this case?
- A. Client's spouse
- B. Medical records
- C. Diagnostic tests
- D. Nursing assessment
Correct Answer: A
Rationale: The correct answer is A: Client's spouse. In the case of an unconscious client, the spouse is the primary source of information about the client's medical history, medications, allergies, and recent events. This information is crucial for providing appropriate care. Medical records may not be immediately accessible. Diagnostic tests provide limited historical information. Nursing assessment relies on the client's condition, which may not provide comprehensive information.