Nokea
Before administering a food feeding the nurse knows to perform which of the following assessments/
- A. The GI tract, including bowel sounds, last BM, and distention
- B. The client’s neurologic status, especially the gag reflex
- C. The amount of air in the stomach
- D. That the formula is used directly from the refrigerator
Correct Answer: A
Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.
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A patient is being given Digoxin to treat heart failure. Which of the ff. is a usual adult daily dosage of digoxin (Lanoxin)?
- A. 0.005 mg
- B. 0.025 mg
- C. 0.25 mg
- D. 2.5 mg
Correct Answer: C
Rationale: Rationale:
C: 0.25 mg is the correct daily dosage of Digoxin for adults with heart failure. This dosage is within the usual range of 0.125-0.25 mg. It helps improve heart function and manage heart failure symptoms.
A: 0.005 mg is too low and ineffective.
B: 0.025 mg is also too low for therapeutic effect.
D: 2.5 mg is too high and may lead to toxicity in most adult patients.
When caring for a patient with AIDS, which of the following nursing actions would be the most appropriate for infection control?
- A. Wear gloves at all times
- B. Wear gown and mask at all times
- C. Wear gloves for blood/body fluid contact
- D. Wear a mask during patient contact times
Correct Answer: C
Rationale: The correct answer is C: Wear gloves for blood/body fluid contact. This is the most appropriate action for infection control when caring for a patient with AIDS because HIV is primarily transmitted through blood and certain body fluids. Wearing gloves when coming into contact with blood or body fluids reduces the risk of transmission.
Explanation for why other choices are incorrect:
A: Wearing gloves at all times may not be necessary and can lead to unnecessary waste of resources.
B: Wearing gown and mask at all times is excessive and not indicated unless there is a risk of exposure to blood or body fluids.
D: Wearing a mask during patient contact times is not necessary unless there is a risk of exposure to respiratory secretions.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.
The staff nurse in a regional hospital is aware that a dose of parenteral ampicillin must be administered within how many hours after it has been mixed?
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 8 hours
Correct Answer: B
Rationale: The correct answer is B (4 hours) because parenteral ampicillin should be administered within 1 hour of mixing. This is crucial to ensure efficacy and prevent bacterial growth in the solution. Choice A (1 hour) is incorrect because it does not allow enough time for administration after mixing. Choice C (2 hours) is also incorrect as it exceeds the recommended time limit. Choice D (8 hours) is incorrect as it exceeds the safe window for administration post-mixing, increasing the risk of bacterial contamination and reduced effectiveness. Thus, the optimal timeframe for administering parenteral ampicillin after mixing is within 4 hours to maintain its therapeutic benefits.
Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: The correct answer is B: Pallor. Pallor, which refers to paleness of the skin, is an early sign of anemia due to decreased red blood cell levels. Anemia causes reduced oxygen delivery to tissues, leading to paleness. Palpitations (A) may occur in anemia but are not an early sign. Glossitis (C) and weight loss (D) are not typically early signs of anemia and are more commonly associated with other health conditions.