Nokea
During surgery, the nurse notices that the patient's temperature is dropping below the normal range. What should the nurse do?
- A. Increase the ambient room temperature in the operating room
- B. Administer a warming blanket or forced-air warming device
- C. Document the temperature trend in the patient's chart
- D. Continue monitoring the patient's temperature closely
Correct Answer: B
Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.
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Transcription of doctor's order is a nurse's responsibility to put the order into action. Which of the following principles of medication safety is NOT considered to belong to transcription error?
- A. Illegible handwriting of the physician.
- B. Misinterpretation of the directions ordered.
- C. Use of unapproved abbreviation in the chart.
- D. Wrong route of medication administration.
Correct Answer: D
Rationale: Transcription errors are typically associated with issues such as illegible handwriting, misinterpretation of directions, and the use of unapproved abbreviations. However, the wrong route of medication administration is not specifically related to transcription errors but rather falls under the category of medication administration errors. Administering medication via the wrong route can lead to serious consequences for the patient and is a separate issue from the act of transcribing doctor's orders.
According to RA 9482 or the anti- Rabies Act of 2007, which of the following statement s regarding rabies post exposure prophylaxis is APPLICABLE?
- A. Have the dogs be regular ly vaccinated against rabies
- B. Do not allow the dog to roam the street.
- C. Put the dog in a leash when in a public place.
- D. The owner will assist the bite victim with the medical expenses . Situation - Roy, 65 years old, came to the outpatient clinic due to dyspnea, fever and on and off productive cough. He smokes one pack of cigarette per day for the last 30 years. The doctor ordered sputum examination, chest x-ray and blood culture.
Correct Answer: A
Rationale: According to RA 9482 or the Anti-Rabies Act of 2007, one of the key components of rabies prevention is to have dogs regularly vaccinated against rabies. This is a crucial step in reducing the risk of rabies transmission from dogs to humans. By ensuring that dogs are vaccinated, the likelihood of rabies exposure is significantly decreased. Additionally, proper vaccination also helps protect the health and well-being of the dogs themselves. Therefore, ensuring regular vaccination of dogs is an applicable and important statement regarding rabies post-exposure prophylaxis as mandated by the law.
Which of the following interventions is most appropriate for a patient with a tension pneumothorax?
- A. Needle decompression
- B. Chest tube insertion
- C. High-flow oxygen therapy
- D. Incentive spirometry
Correct Answer: A
Rationale: A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, causing increased pressure in the chest cavity. This can lead to compression of the lung and major blood vessels, leading to inadequate oxygenation and circulation.
A postpartum client presents with persistent, severe perineal pain despite analgesic medication. On assessment, the nurse observes ecchymosis and swelling of the perineum. Which nursing action is most appropriate?
- A. Applying ice packs to the perineum for pain relief
- B. Encouraging the client to sit on a donut cushion
- C. Notifying the healthcare provider immediately
- D. Administering additional analgesic medication
Correct Answer: C
Rationale: The presence of persistent, severe perineal pain along with ecchymosis and swelling of the perineum can indicate a complication such as a hematoma. A hematoma is a collection of blood that can occur in the perineal area postpartum, usually as a result of trauma during delivery. It is essential to notify the healthcare provider immediately to assess the situation, provide appropriate treatment, and prevent further complications. Applying ice packs or administering additional analgesic medication may not address the underlying issue of a possible hematoma, so prompt medical evaluation is crucial in this situation.
Healthy physical development is dependent upon nutrition, brain development, muscle and bone. Which of the following is NOT APPROPRIATE for physical development of a pre schooler?
- A. Sleeps 6 to 8 hours of sleep each day
- B. Assists in brushing and flossing teeth
- C. Gains 5 pounds per year
- D. Eruption of the primary teeth
Correct Answer: A
Rationale: For a preschooler, it is recommended that they get more than 8 hours of sleep each day. Adequate sleep is crucial for their physical development, overall health, and cognitive function. Preschoolers typically need around 10-13 hours of sleep per day to support their growth and development. Getting less than the recommended amount of sleep can lead to issues such as behavioral problems, difficulty concentrating, and poor physical development. Therefore, ensuring that a preschooler gets enough sleep is vital for their physical well-being.