Nokea
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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The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
- A. Visual disturbances, including diplopia
- B. Ascending paralysis and loss of motor function
- C. Cogwheel rigidity and loss of coordination
- D. Progressive weakness that is worse at the day's end
Correct Answer: D
Rationale: Progressive weakness worse at day's end (fatigue) is classic in myasthenia gravis, due to acetylcholine receptor issues diplopia occurs but isn't primary, ascending paralysis fits Guillain-Barré, and rigidity is Parkinson's. Nurses assess this, aiding diagnosis, key for neuromuscular care.
While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part?
- A. Write the procedure between the two lines of your shift documentation closest to the occurrence.
- B. Find a blank space in your earlier charting, and chart the procedure in that space.
- C. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
- D. Chart the current date and time and 'Late entry,' indicating when and what was done.
Correct Answer: D
Rationale: A late entry with current date, time, and details of the missed procedure is best, maintaining accuracy and legality. Inserting between lines or blank spaces risks confusion, and delegating falsifies records. This method ensures transparency, critical for nursing accountability and care continuity.
What is the term used for a high-pitched musical sound in clients during a respiratory assessment?
- A. Crowing
- B. Wheezing
- C. Stridor
- D. Sigh
Correct Answer: B
Rationale: A high-pitched musical sound during breathing is wheezing, caused by air passing through narrowed airways, often due to asthma, allergies, or obstruction. Stridor is a harsh, high-pitched sound from upper airway obstruction, distinct from wheezing's expiratory nature. Crowing resembles a rooster's call, linked to laryngospasm, not a musical tone. A sigh is a deep breath, not pathological. Wheezing's recognition guides interventions like bronchodilators, addressing underlying inflammation or constriction, crucial for restoring normal respiration and preventing hypoxia.
Which of the following statement best describe health policy?
- A. A hospital rule
- B. Rules affecting health care
- C. A patient's choice
- D. A medical procedure
Correct Answer: B
Rationale: Health policy is rules affecting health care (B), per definition e.g., laws on access. Not hospital (A), patient (C), procedure (D) systemic. B best defines policy's governance, making it correct.
The nurse asked an aide to check Mr. Gary's vitals. This is an example of?
- A. Delegation
- B. Responsibility
- C. Malpractice
- D. Health policy
Correct Answer: A
Rationale: Asking an aide for vitals is delegation (A) task assignment, per definition. Responsibility (B) duty, malpractice (C) breach, policy (D) rules not delegation-specific. A fits the nurse's supervised task for Mr. Gary, making it correct.