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A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
- A. Call the physician
- B. Remedicate the patient
- C. Observe the emesis
- D. Explain to the patient that she can do nothing to help him
Correct Answer: C
Rationale: Observing the emesis checks for medication remnants, guiding next steps.
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Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
What type of patient care model is the most common for student nurses and private duty nurses?
- A. Total patient care
- B. Team nursing
- C. Primary Nursing
- D. Case management
Correct Answer: A
Rationale: Total patient care, where one nurse handles all client needs like meds and hygiene is prevalent for student nurses and private duty nurses. Students benefit from focused, hands-on learning (e.g., managing a post-op patient solo), while private nurses provide personalized attention (e.g., home care). Team nursing splits tasks, primary nursing ensures continuity, and case management coordinates, but total care's simplicity suits training and one-on-one settings. Its direct accountability fosters skill mastery, widely used in educational and private contexts.
The nurse is preparing a client with gout for discharge. Which dietary selection reflects an understanding of the client's condition?
- A. Broiled chicken, rice, and iced tea
- B. Sardines, lima beans, and red wine
- C. Hamburger, fries, and a milkshake
- D. Shrimp, spinach, and beer
Correct Answer: A
Rationale: Broiled chicken, rice, and iced tea suit gout, avoiding purine-rich foods (sardines, shrimp) or alcohol (wine, beer) that raise uric acid lima beans and spinach also contribute less but aren't ideal. Nurses teach this, reducing flare-ups, supporting joint health and client compliance.
A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. Which factor indicates further information is needed by the nurse?
- A. The client's dietary habits include foods high in bulk
- B. The client's fluid intake is between 2500-3000 ml per day
- C. The client engages in moderate exercise each day
- D. The client's bowel habits were not discussed
Correct Answer: D
Rationale: Bowel habits are essential to tailor a training regimen; their absence indicates a gap.
Refers to the pressure when the ventricles are at rest
- A. Diastole
- B. Systole
- C. Preload
- D. Pulse pressure
Correct Answer: A
Rationale: Diastolic pressure is when ventricles rest e.g., 80 in 120/80 showing resistance. Systole (contraction), preload (filling), pulse pressure (difference) differ. Nurses measure this e.g., hypertension for health, per BP definitions.