Nokea
Which of the following actions should the nurse take?
- A. Use the palpatory method to determine blood pressure
- B. Place the arm above the level of the client's heart.
- C. Apply the largest cuff available.
- D. Deflate the cuff quickly.
Correct Answer: A
Rationale: The palpatory method can help obtain a more accurate reading when sounds are difficult to auscultate.
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Which of the following actions should the nurse take?
- A. Limit oral feedings to 30 min in length.
- B. Check the infant's oxygen saturation every 6 hr
- C. Place the infant in the prone position for naps
- D. Weigh the infant every other day.
Correct Answer: A
Rationale: Limiting feeding durations conserves energy for infants with heart failure.
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs
- D. Apply, an orthotic to the client's foot
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. This intervention helps to maintain proper alignment of the foot, preventing contractures that can occur due to prolonged immobility. Placing a pillow under the client's knees (choice A) is beneficial for reducing pressure on the lower back but does not specifically address foot contractures. Similarly, placing a towel roll under the client's neck (choice B) is helpful for neck support but does not prevent foot contractures. Aligning a trochanter wedge between the client's legs (choice C) is aimed at hip alignment and not foot contractures. Therefore, the most appropriate intervention to prevent foot contractures in an immobile client is applying an orthotic to the client's foot.
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
The client asks the nurse if the medication can be given 2 hr. earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when it's convenient for you.
- C. I can infuse the medication at a faster rate.â€
- D. I have up to 2 hours after the usual schedule time to give you this medication.â€
Correct Answer: D
Rationale: The correct answer is D because it adheres to safe medication administration practices. The nurse should explain to the client that there is a window of up to 2 hours after the usual schedule time to administer the medication safely. This ensures that the medication remains effective while also preventing any potential harm from giving it too early or too late.
Choice A is incorrect because starting the medication 30 minutes earlier may not fall within the safe administration window. Choice B is incorrect because adjusting the time solely based on convenience may compromise the medication's effectiveness. Choice C is incorrect because infusing the medication at a faster rate could lead to adverse effects.
For each finding. click to specify if the finding is consistent with pancreatitis or peritonitis Each finding may support more than one disease process.
- A. Bloody stools
- B. Hyperbilirubinemia
- C. Abdominal pain
- D. Elevated WBC court
Correct Answer: A,B,C,D
Rationale: The correct answer is .
Rationale:
1. Bloody stools can be seen in both pancreatitis and peritonitis due to gastrointestinal bleeding.
2. Hyperbilirubinemia is a common finding in pancreatitis due to obstruction of the bile duct by edema or inflammation.
3. Abdominal pain is a hallmark symptom of both pancreatitis and peritonitis, indicating inflammation or irritation of the abdominal structures.
4. Elevated WBC count is a sign of infection or inflammation, which can be present in both pancreatitis and peritonitis.
Summary:
- Bloody stools: Supports both pancreatitis and peritonitis.
- Hyperbilirubinemia: Supports pancreatitis.
- Abdominal pain: Supports both pancreatitis and peritonitis.
- Elevated WBC count: Supports both pancreatitis and peritonitis.
Other choices are incorrect because they do not align with the typical clinical presentations of pancreatitis