Nokea
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
- A. Blood pressure 144/82 mm Hg
- B. Urine specific gravity 1.03
- C. Neck vein distention
- D. Urine specific gravity 1.01
Correct Answer: A
Rationale: The correct answer is A. The elevated blood pressure of 144/82 mm Hg indicates dehydration due to vomiting and diarrhea, leading to hypovolemia. This is a compensatory mechanism by the body to maintain perfusion. Option B, urine specific gravity of 1.03, indicates concentrated urine and dehydration, but not as specific as elevated blood pressure. Option C, neck vein distention, is more indicative of heart failure or fluid overload rather than dehydration. Option D, urine specific gravity of 1.01, indicates diluted urine and is not consistent with dehydration. Therefore, based on the symptoms and the compensatory mechanism of the body, an elevated blood pressure is the most likely finding in a client with vomiting and diarrhea.
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Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP)
indicates the most urgent need for the nurse’s assessment of the patient?
- A. Bedtime glucose of 140 mg/dL
- B. Noon blood glucose of 52 mg/dL
- C. Fasting blood glucose of 130 mg/dL
- D. 2-hr postprandial glucose of 220 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Noon blood glucose of 52 mg/dL. This value indicates hypoglycemia, which can lead to serious complications like confusion, seizures, or coma. Immediate assessment and intervention are crucial.
A: Bedtime glucose of 140 mg/dL is within the normal range.
C: Fasting blood glucose of 130 mg/dL is slightly elevated but doesn't require urgent assessment.
D: 2-hr postprandial glucose of 220 mg/dL is elevated but not as critical as hypoglycemia.
Which of the following is an example of a sentinel event?
- A. A patient fall with no injury
- B. A medication error that results in no harm
- C. A patient suicide while in a healthcare facility
- D. A near miss incident
Correct Answer: C
Rationale: The correct answer is C because a sentinel event is a serious, unexpected occurrence in a healthcare setting that results in death or serious physical or psychological harm to a patient. A patient suicide while in a healthcare facility meets this criteria. A is incorrect as a fall with no injury is not a sentinel event. B is incorrect as a medication error resulting in no harm is not a sentinel event. D is incorrect as a near miss incident, although serious, does not result in harm to the patient.
In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]).
- A. Rotate NPH vial, Inject 20 units of air into NPH vial, Withdraw regular insulin, Inject 2 units of air into regular insulin vial, Withdraw 20 units of NPH.
- B. Rotate NPH vial, Inject 20 units of air into NPH vial, Withdraw regular insulin, Inject 2 units of air into regular insulin vial, Withdraw 20 units of NPH.
- C. Rotate NPH vial, Inject 20 units of air into NPH vial, Inject 2 units of air into regular insulin vial, Withdraw regular insulin, Withdraw 20 units of NPH.
- D. Rotate NPH vial, Inject 20 units of air into NPH vial, Withdraw 20 units of NPH, Inject 2 units of air into regular insulin vial, Withdraw regular insulin.
Correct Answer: C
Rationale: The correct order is C. First, rotate the NPH vial to mix the insulin. Then, inject 20 units of air into the NPH vial to prevent a vacuum. Next, inject 2 units of air into the regular insulin vial to maintain pressure. After that, withdraw the regular insulin to avoid contamination. Finally, withdraw 20 units of NPH, ensuring the correct dosage. This order ensures proper mixing, prevents contamination, and maintains accurate dosing. Other choices have incorrect sequences that may result in inaccurate dosing or contamination.
Which of the following statements is true regarding nursing ethics?
- A. Nursing ethics focus on the organizational level at the workplace.
- B. Nursing ethics focus on the duties and rules of behavior for professional nurses.
- C. Nursing ethics focus on the moral character of nurses.
- D. Nursing ethics focus on the experiences and needs of nurses.
Correct Answer: D
Rationale: Step 1: Nursing ethics encompass principles guiding ethical decision-making.
Step 2: Focusing on the experiences and needs of nurses ensures ethical care delivery.
Step 3: Understanding nurse perspectives enhances patient-centered care.
Step 4: Organizational level (A) is limited, duties and rules (B) are important but not the sole focus, and moral character (C) is crucial but not the main emphasis.
Which level in Maslow's hierarchy is rarely met?
- A. Esteem
- B. Safety
- C. Self-actualization
- D. Belongingness
Correct Answer: C
Rationale: The correct answer is C: Self-actualization. This level in Maslow's hierarchy is rarely met because it represents the highest level of personal growth and fulfillment, where individuals achieve their full potential and self-realization. Most people do not reach this level as it requires a deep understanding of oneself and a continuous journey of personal development. Esteem (A), Safety (B), and Belongingness (D) are more basic needs that are relatively easier to fulfill compared to self-actualization. These lower levels focus on physical and social needs that are essential for survival and well-being, whereas self-actualization involves achieving one's highest aspirations and inner fulfillment.