Nokea
For which client situation would a consultation with a rapid response team (RRT) be most appropriate?
- A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
- B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
- C. 56-year-old fourth hospital day after a coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization.
- D. 86-year-old; 48 hours postoperative repair of a fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter.
Correct Answer: A
Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.
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Which of the following is a primary factor that affects blood pressure?
- A. Obesity
- B. Age
- C. Stress
- D. Gender
Correct Answer: A
Rationale: Obesity is a primary factor that affects blood pressure. Excess body weight, especially when concentrated around the abdomen, can increase the risk of hypertension (high blood pressure) as it puts extra strain on the heart to pump blood around the body. This can lead to various cardiovascular complications and other health issues. Managing weight through a healthy diet and regular physical activity can help control blood pressure levels. Age, stress, and gender can also influence blood pressure but are not primary factors like obesity.
When is aspirin most effective when taken?
- A. On an empty stomach with cold water
- B. On a full stomach after a meal
- C. With a glass of fruit juice
- D. First thing in the morning
Correct Answer: A
Rationale: Aspirin is best absorbed on an empty stomach to maximize its effectiveness. Taking it with cold water helps in its quick absorption. Option B is incorrect because taking aspirin on a full stomach can delay its absorption. Option C is incorrect as fruit juice may not provide the ideal conditions for absorption. Option D is incorrect as taking aspirin first thing in the morning may not ensure an empty stomach.
The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?
- A. Feed the infant with a newborn nipple while holding him in the recumbent position
- B. Clean the suture site with a cotton-tipped swab soaked in Betadine
- C. Place the infant in the prone position after feeding
- D. Feed the infant with a rubber-tipped syringe and burp frequently
Correct Answer: D
Rationale: The correct answer is D because feeding the infant with a rubber-tipped syringe reduces the risk of injury to the surgical site and prevents aspiration. Choice A is incorrect because feeding in the recumbent position can increase the risk of aspiration. Choice B is incorrect as Betadine is not recommended for wound care near the mouth due to its potential toxicity if ingested. Choice C is incorrect because placing the infant in the prone position after feeding can increase the risk of regurgitation and aspiration.
Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?
- A. It is a problem-focused process of continued nursing care
- B. It is an open-ended process of continued nursing care
- C. It is a circular process of continued nursing care
- D. It is a trial-and-error process of continued nursing care
Correct Answer: C
Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation is a continuous and cyclical process in nursing care. Choice A is incorrect because the method is not solely problem-focused but involves multiple steps. Choice B is incorrect as it does not capture the structured nature of the four-step method. Choice D is incorrect as it implies a random approach rather than a systematic and organized process.
The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)
- A. The nursing assistant aspirates and measures the amount of gastric aspirate
- B. The nursing assistant elevates the head of the client's bed 30 degrees
- C. The nursing assistant warms the formula to room temperature
- D. B, C
Correct Answer: D
Rationale: The correct answer is D because elevating the head of the bed reduces the risk of aspiration, and warming the formula to room temperature helps prevent discomfort and complications. Choice A is incorrect as only licensed healthcare professionals should aspirate and measure the amount of gastric aspirate. Choice B is correct as it helps prevent aspiration. Choice C is correct as warming the formula can prevent discomfort.