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An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: C
Rationale: Upon arrival, checking the lungs for equal breath sounds bilaterally is the first action. This is crucial to assess airway patency and breathing effectiveness in a patient with a history of diving accident and intubation. Ensuring proper oxygenation takes precedence over other actions. Taking vital signs, inserting an IV line, and performing a neurologic check can wait until airway and breathing are adequately assessed.
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As part of primary cancer prevention program, an oncology nurse answers questions from the public at health fair. When someone asks about the laryngeal cancer, the nurse should explain that:
- A. Laryngeal cancer is one of the most preventable types of cancer
- B. Inhaling polluted air isn’t a risk factor for laryngeal cancer
- C. Laryngeal cancer occurs primarily in women
- D. Adenocarcinoma accounts for most cases of laryngeal cancer
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Laryngeal cancer is strongly linked to smoking and alcohol consumption.
2. Both smoking and alcohol use are modifiable risk factors, meaning they can be prevented.
3. By avoiding smoking and excessive alcohol intake, individuals can significantly reduce their risk of developing laryngeal cancer.
4. Therefore, laryngeal cancer is considered one of the most preventable types of cancer.
Summary of why the other choices are incorrect:
B. Inhaling polluted air can be a risk factor for laryngeal cancer, so this statement is inaccurate.
C. Laryngeal cancer occurs more frequently in men than women, so this statement is incorrect.
D. Squamous cell carcinoma, not adenocarcinoma, is the most common type of laryngeal cancer, making this statement incorrect.
A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
- A. To restore and maintain intravascular volume
- B. To provide a means for further comparison and evaluation
- C. To avoid interference with wound drainage
- D. To prevent pain related to obstruction
Correct Answer: B
Rationale: The correct answer is B: To provide a means for further comparison and evaluation. By recording the color of drainage from each tube and catheter, the nurse can monitor changes over time, assess for any abnormalities, and evaluate the effectiveness of treatment. This helps in detecting complications early and making informed decisions.
Rationale for other choices:
A: To restore and maintain intravascular volume - Monitoring drainage color does not directly relate to intravascular volume status.
C: To avoid interference with wound drainage - Monitoring drainage color does not prevent interference with wound drainage.
D: To prevent pain related to obstruction - Monitoring drainage color does not directly prevent pain related to obstruction.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
- A. Level of awareness and response to pain
- B. Papillary reflexes and response to sensory stimuli
- C. Coherence and sense of hearing
- D. Patency of airway and adequacy of respiration
Correct Answer: D
Rationale: The correct answer is D: Patency of airway and adequacy of respiration. During the acute stage of an unconscious patient like Mr. Franco, ensuring the airway is open and that breathing is adequate is the top priority to maintain oxygenation and prevent complications like hypoxia. This assessment is crucial for immediate intervention and can be life-saving.
A: Level of awareness and response to pain may provide important information but is secondary to ensuring a patent airway and adequate breathing in an unconscious patient.
B: Pupillary reflexes and response to sensory stimuli are important neurological assessments, but airway and breathing take precedence in the acute stage to maintain vital functions.
C: Coherence and sense of hearing are not as critical as assessing and maintaining the airway and breathing in an unconscious patient.
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In the scenario, the nurse failed to assess the patient's condition promptly after the patient complained of feeling dizzy and light-headed. Assessment is the first phase of the nursing process and involves collecting data to identify the patient's health status. By not reassessing the patient's vital signs and symptoms, the nurse missed an opportunity to detect the worsening condition. The other choices are incorrect because the error occurred before diagnosis (B), implementation (C), and evaluation (D) phases. In diagnosis, the nurse identifies the patient's problems; in implementation, the nurse carries out the care plan; and in evaluation, the nurse assesses the effectiveness of interventions.
Which of the ff. does the nurse understand are the reasons a patient with pulmonary edema is given morphine sulphate? i.To reduce anxiety iv.To increase BP ii.To relieve chest pain v.To reduce preload and afterload iii.To strengthen heart contractions
- A. 2 and 4
- B. 3 and 5
- C. 1 and 5
- D. 2 and 3
Correct Answer: C
Rationale: The correct answer is C because morphine sulfate is given to a patient with pulmonary edema to reduce anxiety (i) and to reduce preload and afterload (v). Morphine sulfate does not increase blood pressure (ii), relieve chest pain (iii), or strengthen heart contractions (iv) in the context of pulmonary edema. Choice A is incorrect because it includes increasing BP, which is not a reason for giving morphine sulfate in this case. Choice B is incorrect because it includes strengthening heart contractions, which is not a reason for administering morphine sulfate. Choice D is incorrect because it includes relieving chest pain, which is not a primary purpose of giving morphine sulfate to a patient with pulmonary edema.