Nokea
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
- A. Complete set of vital signs
- B. Palpation and auscultation of the abdomen
- C. Brief neurologic assessment
- D. Initiation of pulse oximetry
Correct Answer: C
Rationale: A brief neurologic assessment helps quickly identify potential brain injuries or other neurological deficits.
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16. Which statement accurately describes the common use of feverfew?
- A. Frequently used for insomnia and anxiety
- B. Most commonly used for prevention of migraine headaches
- C. Frequently used to prevent and treat upper respiratory infections
- D. Often used by perimenopausal women to relieve menopausal symptoms
Correct Answer: B
Rationale: Feverfew is most commonly used for the prevention of migraine headaches, making option B the correct answer.
A nurse cares for a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
- A. I plan to wear my oxygen when I exercise & feel short of breath.
- B. I will use my portable oxygen when grilling burgers in the backyard.
- C. I plan to use cotton balls to cushion the oxygen tubing on my ears.
- D. I will only smoke while I am wearing my oxygen via nasal cannula.
Correct Answer: C
Rationale: The correct answer is C because using cotton balls to cushion the oxygen tubing on the ears helps prevent skin irritation or pressure ulcers. This indicates the client understands the importance of skin care and comfort while using oxygen therapy.
A: Incorrect. The client should wear oxygen during all activities that increase oxygen demand, not just when feeling short of breath during exercise.
B: Incorrect. Using portable oxygen near an open flame like a grill can result in a fire hazard.
D: Incorrect. Smoking while using oxygen therapy is extremely dangerous and can lead to a fire.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What action should the nurse anticipate?
- A. Decrease the heparin rate.
- B. Increase the heparin rate.
- C. No change to the heparin rate.
- D. Stop the heparin; start warfarin (Coumadin).
Correct Answer: B
Rationale: The correct answer is B: Increase the heparin rate. A PTT of 25 seconds indicates that the client's blood is not adequately anticoagulated, as the therapeutic range for PTT is typically around 60-80 seconds for heparin therapy. Therefore, the nurse should anticipate increasing the heparin rate to achieve the desired anticoagulant effect and prevent further clot formation.
Incorrect choices:
A: Decreasing the heparin rate would further decrease the anticoagulant effect, potentially putting the client at risk for thrombus progression.
C: No change to the heparin rate would not address the subtherapeutic PTT level and could lead to inadequate anticoagulation.
D: Stopping heparin and starting warfarin is not appropriate at this time as warfarin takes time to reach therapeutic levels, whereas heparin provides immediate anticoagulation for acute situations like a pulmonary embolism.
Joan asks you why she is being administered so many arterial blood gas tests. You respond by saying
- A. This test determines if your liver and kidneys are functioning properly.
- B. This test determines if you have sufficient WBC to fight infection.
- C. This test determines if you are hyperglycemic, which is a side effect of your medication.
- D. This test determines how well your tissues are oxygenated.
Correct Answer: D
Rationale: Arterial blood gas tests measure oxygenation and acid-base balance in the blood.
The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would the nurse anticipate finding?
- A. Large volume of urinary output with each voiding.
- B. Involuntary voiding with coughing and sneezing.
- C. Frequent urination.
- D. Urine is dark and concentrated.
Correct Answer: C
Rationale: Frequent urination is common due to urethral obstruction.