Nokea
Blood pressure in the systemic circulation is highest in the:
- A. Arterioles
- B. Capillaries
- C. Aorta
- D. Venules
Correct Answer: C
Rationale: Blood pressure is highest in the aorta, where blood is ejected directly from the left ventricle during systole, generating peak pressure (systolic pressure). As blood flows through arterioles, capillaries, and venules, pressure progressively decreases due to resistance and vessel compliance. This makes the aorta the correct answer.
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The nurse formulates a nursing diagnosis of Spiritual distress related to advanced cancer disease. An appropriate goal for the client would be to:
- A. Start attending church or chapel services once a week.
- B. Call a chaplain and set up an appointment for spiritual guidance.
- C. Reflect on past accomplishments.
- D. Participate in spiritual activities of the client's choice.
Correct Answer: D
Rationale: Participating in spiritual activities of the client's choice respects their individual beliefs and supports resolution of spiritual distress.
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.
After the initial phase of the burn injury, the client's plan of care will focus primarily on:
- A. Helping the client maintain a positive selfconcept.
- B. Promoting hygiene.
- C. Everything infection.
- D. Educating the client regarding care of the skin grafts.
Correct Answer: C
Rationale: Infection prevention is critical in the acute phase of burn care, as burns compromise the skin's barrier, increasing infection risk. Other options are secondary priorities.
The nurse is applying a hand mitt restraint for a client with pruritis (see figure). The nurse should be:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: A physician's order is required for restraints to ensure legal and ethical use, prioritizing patient safety and preventing scratching in pruritus.
The nurse is preparing to administer an intradermal injection. Which of the following would be appropriate action by the nurse?
- A. Displace the skin to the side and inject at a 15 degree angle
- B. Position the needle bevel up at 15 degrees
- C. Position the needle bevel up at 45 degrees
- D. Position the needle bevel up at 90 degrees with a dart-like motion
Correct Answer: B
Rationale: Intradermal injections require a 15-degree angle with the bevel up to ensure shallow administration.