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A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration?
- A. Trough
- B. Peak
- C. Half-life
- D. Toxic
Correct Answer: A
Rationale: The correct answer is A: Trough. The trough level represents the lowest serum concentration of a medication in the body, usually measured just before the next dose is administered. This is important in monitoring the effectiveness and safety of the drug. Peak levels (B) indicate the highest concentration. Half-life (C) refers to the time it takes for half of the drug to be eliminated from the body. Toxic levels (D) are when the drug concentration is too high and can lead to harmful effects. Other choices are not relevant to the lowest serum concentration.
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A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach the use of an incentive spirometer to a postoperative client
- B. Irrigate and perform a dressing change for a client who has a pressure injury wound
- C. Administer oral PRN pain medication to a client who has arthritis
- D. Obtain a daily weight on a client who has heart failure
Correct Answer: D
Rationale: The correct answer is D: Obtain a daily weight on a client who has heart failure. The rationale is as follows: Delegating the task of obtaining a daily weight to an assistive personnel (AP) is appropriate because it is a routine, non-invasive task that does not require specialized knowledge or skills. Daily weight monitoring is crucial for clients with heart failure to assess for fluid retention or loss, which is essential for managing the condition effectively. APs are trained to perform basic tasks like measuring weight and can report any significant changes to the nurse for further evaluation.
Summary of why the other choices are incorrect:
A: Teaching the use of an incentive spirometer requires specialized knowledge and skill that only a nurse should perform.
B: Irrigating and performing a dressing change for a pressure injury wound requires sterile technique and assessment skills that are beyond the scope of an AP.
C: Administering PRN pain medication involves assessing the client's condition, pain level, and potential side effects,
A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
- A. Keep the head of the client’s bed elevated to 45
- B. Provide the client with a high-calorie diet
- C. Massage the client’s bony prominences
- D. Reposition the client every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Provide the client with a high-calorie diet. A high-calorie diet can help promote tissue healing and prevent pressure injuries by providing the necessary nutrients for skin integrity. Keeping the head of the bed elevated to 45 degrees (A) is important for preventing aspiration but not directly related to preventing pressure injuries. Massaging bony prominences (C) can actually increase the risk of pressure injuries by causing friction and shear forces. Repositioning the client every 4 hours (D) is essential but not directly related to the prevention of pressure injuries.
A nurse is caring for a client with a scheduled procedure. While preparing the client for transport they appear anxious and ask the nurse where they should hide their cellphone during the procedure. The nurse offers to lock the item in a secure area. Which category of Maslow's hierarchy of needs is the nurse addressing?
- A. Safety needs
- B. Esteem needs
- C. Love and belonging needs
- D. Physiological needs
Correct Answer: A
Rationale: The correct answer is A: Safety needs. At this moment, the nurse is addressing the client's need for safety by offering to secure their cellphone. Safety needs in Maslow's hierarchy refer to feeling secure, stable, and protected. By ensuring the client's belongings are safe, the nurse is addressing this fundamental need, which is crucial for the client's well-being during the procedure. Other choices are incorrect because: B: Esteem needs focus on self-respect and recognition from others, C: Love and belonging needs refer to relationships and social connections, and D: Physiological needs pertain to basic requirements like food and water, none of which are directly addressed in this scenario.
A nurse is documenting client care including only unexpected findings related to the client's condition. Which of the following documentation methods is the nurse utilizing?
- A. SOAP documentation
- B. Focus charting (DAR)
- C. Charting by exception (CBE)
- D. Problem-oriented medical record (POMR)
Correct Answer: C
Rationale: Charting by exception (CBE) is the correct answer. CBE involves documenting only significant findings or exceptions to the norm. This method focuses on deviations from the expected baseline, promoting efficiency and highlighting important changes in the client's condition. By documenting unexpected findings related to the client's condition, the nurse is using CBE to streamline the documentation process and prioritize critical information. SOAP documentation (A) involves subjective, objective, assessment, and plan format, which is more comprehensive. Focus charting (DAR) (B) focuses on data, action, and response but does not specifically target unexpected findings. Problem-oriented medical record (POMR) (D) emphasizes problem lists, making it less focused on exceptions.
A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?
- A. Cataracts
- B. Diabetic retinopathy
- C. Macular degeneration
- D. Glaucoma
Correct Answer: A
Rationale: The correct answer is A: Cataracts. Cataracts cause a cloudy, opaque area over the lens of the eye, leading to blurred vision. This occurs due to the clouding of the lens from protein buildup. Diabetic retinopathy, choice B, involves damage to blood vessels in the retina due to diabetes. Macular degeneration, choice C, affects the central part of the retina leading to distortion or loss of central vision. Glaucoma, choice D, is characterized by increased pressure within the eye damaging the optic nerve. In this scenario, the cloudy, opaque area over the lens specifically points towards cataracts, making it the correct choice.