Nokea
A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient?
- A. Start oxygen at 2 L/min
- B. Initiate cardiac monitoring
- C. Initiate seizure precautions
- D. Keep the patient on bed rest
Correct Answer: B
Rationale: The correct answer is to initiate cardiac monitoring. Severe hypokalemia can lead to life-threatening arrhythmias, making cardiac monitoring the priority to detect and manage any cardiac complications. Starting oxygen, seizure precautions, or bed rest are not the immediate priority actions for severe hypokalemia.
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Which statement about glaucoma is true and accurate?
- A. Acute angle-closure glaucoma is an ocular emergency.
- B. Acute angle-closure glaucoma leads to the loss of peripheral vision and tunnel vision.
- C. Primary open-angle glaucoma leads to eye pain, nausea, and vomiting, blurry vision, and halos.
- D. Bubbles are implanted to protect the retina from glaucoma.
Correct Answer: A
Rationale: The correct answer is A: 'Acute angle-closure glaucoma is an ocular emergency.' Acute angle-closure glaucoma is indeed considered an ocular emergency that requires immediate attention to prevent vision loss. Choice B is incorrect because acute angle-closure glaucoma commonly presents with symptoms like severe eye pain, headache, blurred vision, and halos around lights. Choice C is incorrect as these symptoms are more indicative of acute angle-closure glaucoma rather than primary open-angle glaucoma. Choice D is incorrect since bubbles are not typically used to protect the retina from glaucoma; treatment usually involves medications, laser therapy, or surgery to manage intraocular pressure.
What is an episiotomy?
- A. A surgical incision of the perineum to prevent tearing during delivery.
- B. Releasing the red plug from the cervix just before crowning occurs.
- C. An incision in the abdomen with which the baby can be delivered through.
- D. The severance of the umbilical cord between mother and child.
Correct Answer: A
Rationale: An episiotomy is a surgical incision of the perineum to prevent tearing during delivery. This procedure is performed to widen the vaginal opening and facilitate childbirth. Choice B is incorrect as it describes the expulsion of the mucus plug, not an episiotomy. Choice C is incorrect as it refers to a different procedure, a cesarean section, where the baby is delivered through an incision in the abdomen. Choice D is incorrect as it pertains to cutting the umbilical cord, which is not related to an episiotomy.
Insulin forces which of the following electrolytes out of the plasma and into the cells?
- A. Calcium
- B. Magnesium
- C. Phosphorus
- D. Potassium
Correct Answer: D
Rationale: Insulin forces potassium out of the plasma and into the cells, which can cause hypokalemia. This is because insulin enhances the activity of the sodium-potassium pump in cell membranes, promoting the movement of potassium from the extracellular fluid into the cells. Choices A, B, and C are incorrect as insulin does not directly influence the movement of calcium, magnesium, or phosphorus in the same manner as it does with potassium.
A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following should the nurse take first?
- A. Refer the AP to the facility procedure manual
- B. Demonstrate the proper client transfer technique for the AP
- C. Instruct the AP to request assistance when unsure about a task
- D. Help the AP assist the client with the transfer
Correct Answer: D
Rationale: The correct first action for the nurse is to ensure the safety of the client by immediately intervening to help the AP with the transfer. This hands-on assistance can prevent any potential harm to the client. Referring the AP to the facility procedure manual (Choice A) might take time and delay the necessary immediate action. Demonstrating the proper technique (Choice B) can be done after ensuring the client's safety. Instructing the AP to request assistance (Choice C) is not the most urgent step when a client's safety is at risk.
Which patient is exercising their right to autonomy in the context of patient rights?
- A. An 86-year-old female who remains independent in terms of the activities of daily living.
- B. An unemancipated 16-year-old who chooses to not have an intravenous line.
- C. A 32-year-old who does not need the help of the nurse to bathe and groom themselves.
- D. A 99-year-old who wants CPR despite the fact that the nurse and doctor do not think that it would be successful.
Correct Answer: D
Rationale: The correct answer is D. A 99-year-old exercising their right to autonomy in the context of patient rights by choosing CPR. Autonomy in healthcare refers to the patient's right to make their own decisions about their care, even if healthcare providers may disagree. In this scenario, the 99-year-old patient is exercising autonomy by making an informed choice about their medical treatment, despite healthcare professionals having a different opinion. Choices A, B, and C do not directly demonstrate the exercise of autonomy in decision-making regarding medical treatment, making them incorrect.