Nokea
Considered as the most accessible and convenient method for temperature taking
- A. Oral
- B. Rectal
- C. Tympanic
- D. Axillary
Correct Answer: A
Rationale: Oral temp is most accessible e.g., quick tongue placement needing minimal prep, unlike rectal (invasive), tympanic (equipment), or axillary (longer). Convenient for alert patients, nurses favor it e.g., clinics for routine ease, per practice standards.
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A client is receiving 115 ml/hr of continuous IVF. The nurse noticed that the venipuncture site was red and swollen. Which of the following interventions would the nurse perform first?
- A. Stop the infusion
- B. Call the attending physician
- C. Slow that infusion to 20 ml/hr
- D. Place a cold towel on the site
Correct Answer: A
Rationale: Stopping the infusion is the nurse's first intervention when observing a red, swollen venipuncture site, as this may indicate phlebitis, infiltration, or infection. Halting the IV prevents further tissue damage or fluid extravasation, prioritizing patient safety. Redness and swelling suggest inflammation or leakage into surrounding tissue, requiring immediate cessation to assess severity and plan next steps, like site relocation or physician consultation. Calling the physician follows assessment, not precedes stopping the infusion, as the nurse acts within scope to mitigate harm first. Slowing the infusion might worsen damage if fluid is already escaping the vein. A cold towel could reduce swelling later but doesn't address the active infusion causing the issue. Stopping the infusion is the critical initial step, enabling evaluation and preventing complications, aligning with nursing's focus on prompt, protective action.
Mr. Gary lost his job and feels overwhelmed. This is an example of?
- A. Crisis
- B. Illness
- C. Disability
- D. Stress
Correct Answer: A
Rationale: Job loss feeling overwhelming is a crisis (A) sudden disruption, per definition. Illness (B) is disease, disability (C) loss, stress (D) response not event-specific. A fits acute imbalance, making it correct.
How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?
- A. 5
- B. 10
- C. 15
- D. 30
Correct Answer: D
Rationale: After activity, smoking, or caffeine e.g., raising BP 30 minutes rest ensures accuracy, per AHA guidelines. Shorter times (5-15 min) risk false highs. Nurses enforce this e.g., post-exercise delay for reliable readings, standard in clinical assessment protocols.
What is nurse's primary critical observation when performing an assessment for determining an Apgar score?
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of Moro reflex
Correct Answer: A
Rationale: Apgar score assesses newborn vitality at 1 and 5 minutes post-birth across five criteria: heart rate, respiration, muscle tone, reflex, color. Heart rate (choice A) is primary; absent (<60 bpm = 0, <100 = 1, >100 = 2) dictates immediate resuscitation, making it the most critical. Respiratory rate (choice B) follows, but weak/absent breathing often ties to heart rate. Meconium (choice C) isn't scored directly, though it flags distress. Moro reflex (choice D) tests tone/reflex, secondary to vitals. A is correct, as heart rate drives initial intervention. Nurses prioritize it, ensuring rapid response to stabilize the infant.
The nurse is caring for a client with a T4 spinal cord injury. Which finding indicates that the client is experiencing neurogenic shock?
- A. Blood pressure 82/40 mm Hg, pulse 48 beats/min
- B. Blood pressure 150/90 mm Hg, pulse 110 beats/min
- C. Blood pressure 110/70 mm Hg, pulse 88 beats/min
- D. Blood pressure 130/80 mm Hg, pulse 62 beats/min
Correct Answer: A
Rationale: Neurogenic shock in T4 SCI features hypotension and bradycardia (A, 82/40, 48 bpm) from sympathetic loss. Hypertension/tachycardia (B) suggests dysreflexia. C and D are normalish. A is correct. Rationale: Loss of vasomotor tone below T4 causes vasodilation and unopposed vagal activity, per SCI pathophysiology, requiring fluids and atropine.