Nokea
A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
- A. A client who reports right-sided flank pain and is diaphoretic
- B. A client who has active bleeding from a puncture wound of the left groin area
- C. A client who has a raised red skin rash on his arms, neck, and face
- D. A client who reports shortness of breath and left neck and shoulder pain
Correct Answer: D
Rationale: The correct answer is D because shortness of breath with referred pain may indicate a serious condition, such as a cardiac event or pulmonary embolism, making this the highest priority. Option A, flank pain with diaphoresis, could suggest kidney-related issues but is not as immediately life-threatening as compromised breathing. Option B, active bleeding, though serious, can usually be controlled with proper interventions. Option C, a raised red skin rash, may indicate an allergic reaction but is not as urgent as respiratory distress with neck and shoulder pain.
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The doctor has ordered 20 cc per hour of normal saline intravenously for your pediatric patient. You will be using pediatric intravenous tubing that delivers 60 cc per drop. How many drops per minute will you administer using this pediatric intravenous set?
- A. 30 drops per minute
- B. 25 drops per minute
- C. 20 drops per minute
- D. 22 drops per minute
Correct Answer: C
Rationale: To calculate the drops per minute, first convert the ordered amount to drops per minute. 20 cc per hour equals 20 drops per hour with 60 cc per drop tubing, which is equivalent to 20 drops per hour * 60 cc per drop = 1200 drops per hour. To find drops per minute, divide 1200 by 60 (minutes in an hour), which equals 20 drops per minute. Therefore, the correct answer is 20 drops per minute. Choices A, B, and D are incorrect as they do not reflect the correct calculation based on the provided information.
In which position will you place your patient when they are demonstrating the signs and symptoms of hypovolemic shock?
- A. The Trendelenburg position
- B. The supine position
- C. The left lateral position
- D. The right lateral position
Correct Answer: A
Rationale: The correct answer is A, the Trendelenburg position. This position involves placing the patient with their legs elevated higher than their head. It is used to increase blood flow to the upper body, including the brain and heart, in cases of hypovolemic shock. This helps improve perfusion to vital organs. Choices B, C, and D are incorrect as they do not facilitate the desired redistribution of blood flow needed in hypovolemic shock. The supine position is lying flat on the back, the left lateral position is lying on the left side, and the right lateral position is lying on the right side.
A client with diabetes experiences Somogyi's effect. To prevent this complication, the nurse should instruct the client to:
- A. Take insulin at 2:00 PM each day
- B. Engage in physical activity daily
- C. Increase the dose of regular insulin
- D. Eat a protein and carbohydrate snack at bedtime
Correct Answer: D
Rationale: Somogyi effect, also known as rebound hyperglycemia, occurs as a response to nighttime hypoglycemia. Eating a protein and carbohydrate snack at bedtime can help prevent this by stabilizing blood sugar levels throughout the night. Instructing the client to take insulin at 2:00 PM each day (Choice A) may not directly address the nighttime hypoglycemia concern. Engaging in physical activity daily (Choice B) is generally beneficial for diabetes management but may not specifically prevent Somogyi's effect. Increasing the dose of regular insulin (Choice C) without addressing the nighttime hypoglycemia issue can exacerbate the problem.
During which stage of anesthesia is a patient most likely to experience involuntary motor activity?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage VI
Correct Answer: B
Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements.
Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur.
Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage.
Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.
When a woman has miscarried in three or more consecutive pregnancies, it is referred to as which type of spontaneous abortion?
- A. Inevitable
- B. Missed
- C. Habitual
- D. Threatened
Correct Answer: C
Rationale: The correct answer is C, 'Habitual.' Habitual abortion is defined as three or more consecutive miscarriages, making it the appropriate term for this situation. Choice A, 'Inevitable,' refers to a miscarriage that cannot be prevented. Choice B, 'Missed,' refers to a miscarriage where the fetus has died but has not been expelled. Choice D, 'Threatened,' refers to a situation where there is bleeding in early pregnancy but the cervix remains closed.