Nokea
In instilling the eye drops you have to tilt the back slightly Claudia's head. Which of the following is the RATIONALE for this nursing action?
- A. To prevent any spill from the eye during the procedure
- B. To keep any debris away from the lacrimal duct
- C. To facilitate the procedure
- D. To reach the conjunctival sac easily
Correct Answer: D
Rationale: Tipping Claudia's head back slightly helps in reaching the conjunctival sac easily. The conjunctival sac is a small space between the lower eyelid and the eye itself where eye drops are typically administered. Tilting the head back allows for better access to this area, ensuring the eye drops are delivered accurately and effectively into the eye.
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Right after endorsement and during the rounds, the incoming nurse observes that the IV fluid is at 800 cc level and not 400cc, as endorsed. What is the CORRECT information that she will chart?
- A. Anything goes, nobody reads the charting anyway.
- B. Record the 400 cc.
- C. Chart that she received 800
- D. Refer to the Head Nurse on what to do.
Correct Answer: C
Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.
What drug should the nurse prepare for administration to reverse all signs of toxicity?
- A. Digibind (Digoxin)
- B. Atropine sulfate
- C. Naloxone (Narcan)
- D. Diazepam (Valium)
Correct Answer: C
Rationale: Naloxone, also known by the brand name Narcan, is used to reverse the effects of opioid overdose. Opioids can cause respiratory depression, sedation, and other signs of toxicity. Administering naloxone can quickly reverse these effects, restoring the patient's breathing and consciousness. This makes it the appropriate choice for reversing all signs of toxicity related to opioids. Digibind (Digoxin) is used to reverse toxicity from digoxin specifically. Atropine sulfate is used for bradycardia. Diazepam (Valium) is a benzodiazepine used for anxiety, seizures, and muscle relaxation, not for reversing toxicity.
A woman in active labor requests hydrotherapy for pain relief. What is the nurse's priority action before initiating hydrotherapy?
- A. Obtain informed consent from the mother.
- B. Ensure that the labor room is equipped with a hydrotherapy tub.
- C. Assess the maternal and fetal conditions for eligibility.
- D. Review the mother's medical history for contraindications.
Correct Answer: C
Rationale: Before initiating hydrotherapy for pain relief during labor, the nurse's priority action should be to assess the maternal and fetal conditions to determine if the mother is eligible for this form of pain management. It is essential to ensure that hydrotherapy is safe and appropriate for the specific situation. Assessing the maternal condition includes evaluating factors such as the stage of labor, maternal and fetal well-being, and any medical conditions that could impact the use of hydrotherapy. This assessment helps to identify any contraindications or risks that may affect the mother and baby during hydrotherapy. By conducting a thorough assessment, the nurse can make an informed decision about whether hydrotherapy is suitable for the woman in labor.
A patient presents with a Colles' fracture. What is the characteristic deformity associated with this type of fracture?
- A. Dorsal displacement of the distal fragment
- B. Ventral displacement of the distal fragment
- C. Lateral displacement of the distal fragment
- D. Medial displacement of the distal fragment
Correct Answer: A
Rationale: Colles' fracture is a type of distal radius fracture characterized by a break of the radius bone in the forearm close to the wrist. In a Colles' fracture, the distal fragment of the fractured radius bone gets displaced dorsally, meaning it shifts upwards towards the back of the hand, creating a characteristic "dinner fork" deformity when viewed from the side. This dorsal displacement results in a visible bump on the back of the wrist and a noticeable deformity when compared to the uninjured side.
The nurse, as the community organizer, immerses self by joining local folks in their usual everyday activities in ordwwer to ______.
- A. gain trust and rapport of people
- B. make self popular among people
- C. identify and spot leaders
- D. become familiar with the place
Correct Answer: A
Rationale: Immersing oneself in the local community and participating in their everyday activities allows the nurse, as a community organizer, to establish trust and build rapport with the people. By actively engaging with the community members, the nurse can show genuine interest and commitment to their well-being, which fosters a sense of connection and mutual understanding. This approach is crucial for gaining the trust of the community, as it demonstrates that the nurse is invested in listening to their needs and working together to address health concerns effectively.