Nokea
A patient is receiving a continuous infusion of morphine via an epidural catheter following major abdominal surgery. Which actions should the nurse include in the plan of care (select all that apply)?
- A. Label the catheter as an epidural access
- B. Assess the patient’s pain relief frequently
- C. Use sterile technique when caring for the catheter
- D. Monitor the patient’s level of consciousness (LOC)
Correct Answer: B
Rationale: The correct answers are B. All listed actions are essential for safe and effective care.
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What is the term used for assessment data that the patient tells you about?
- A. Focused
- B. Objective
- C. Subjective
- D. Comprehensive
Correct Answer: C
Rationale: The correct answer is 'Subjective.' Subjective data includes patient-reported symptoms, feelings, and experiences.
Chemotherapeutic treatment of acute leukemia is done in four phases. Place these phases in the correct order.
- A. Maintenance.
- B. Induction.
- C. Intensification.
- D. Consolidation.
Correct Answer: B
Rationale: Induction is the initial phase aimed at achieving remission, followed by consolidation, intensification, and maintenance.
Felicia's family is concerned because Felicia states that she is hearing voices. This is a sign of
- A. Bipolar disorder.
- B. Schizophrenia.
- C. Panic disorder.
- D. Bulimia nervosa.
Correct Answer: B
Rationale: Auditory hallucinations are a hallmark symptom of schizophrenia.
Which manipulative and body-based technique uses pressure applied to the feet and hands?
- A. Massage
- B. Reflexology
- C. Shiatsu
- D. Chiropractic technique
Correct Answer: B
Rationale: Reflexology applies pressure to specific points on the feet and hands, stimulating corresponding body areas.
What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is relevant because equal AP and lateral chest diameters can indicate a barrel chest, which is often associated with chronic breathing problems like chronic obstructive pulmonary disease (COPD). Chronic breathing problems can lead to this specific chest shape due to increased lung volume. Choice A is incorrect as it does not directly relate to the physical assessment findings. Choice C is incorrect as it focuses on exercise habits rather than the client's current health status. Choice D is incorrect as it does not address the potential underlying health issue indicated by the chest measurements.