Nokea
In monitoring the patient in PACU, the nurse correctly identifies that checking the patient's vital signs is done every:
- A. 1 hour
- B. 5 minutes
- C. 15 minutes
- D. 30 minutes
Correct Answer: A
Rationale: Correct Answer: A - Vital signs monitoring in the PACU (Post-Anesthesia Care Unit) is typically done every hour to closely monitor the patient's condition during the immediate postoperative period. This frequency allows the nurse to promptly identify any changes in the patient's vital signs and intervene as necessary. Choice B (5 minutes) is too frequent for routine vital signs monitoring in the PACU and may not allow for a comprehensive assessment of the patient's stability. Choice C (15 minutes) and Choice D (30 minutes) are also not in line with the standard practice of vital signs monitoring in the PACU, which is typically hourly.
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During which step of the nursing process does the nurse analyze data related to the patient's health status?
- A. Assessment
- B. Implementation
- C. Diagnosis
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is 'Assessment.' During the assessment phase of the nursing process, the nurse collects and analyzes data related to the patient's health status. This involves gathering information through various means such as patient interviews, physical examinations, and reviewing medical records. Choice B, 'Implementation,' refers to the phase where the nurse carries out the planned interventions. Choices C and D, 'Diagnosis' and 'Evaluation,' come after the assessment phase in the nursing process.
All of the following are seen in a child with measles. Which one is not?
- A. Reddened eyes
- B. Coryza
- C. Pustule
- D. Cough
Correct Answer: C
Rationale: Measles typically presents with symptoms like reddened eyes, coryza (inflammation of the mucous membrane in the nose), and cough. However, pustules are not a common symptom of measles. Pustules are more characteristic of conditions like chickenpox rather than measles. Understanding these distinctions is crucial for accurate diagnosis and appropriate treatment.
An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?
- A. Marijuana
- B. Amphetamines
- C. Barbiturates
- D. Anxiolytics
Correct Answer: A
Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.
A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?
- A. Fluid volume overload
- B. Sepsis
- C. Hyperglycemia
- D. Hypoglycemia
Correct Answer: D
Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.
Which of the following is a form of primary prevention?
- A. Regular Check-ups
- B. Regular Screening
- C. Self-Medication
- D. Immunization
Correct Answer: D
Rationale: The correct answer is D, 'Immunization.' Primary prevention aims to prevent disease before it occurs by preventing exposure to risk factors. Immunization is a classic example of primary prevention as it helps prevent the development of infectious diseases. Choice A, 'Regular Check-ups,' is more related to secondary prevention by detecting diseases early. Choice B, 'Regular Screening,' is also more aligned with secondary prevention as it involves early detection of diseases. Choice C, 'Self-Medication,' is not a form of primary prevention but rather a risky practice that can lead to adverse outcomes.