Nokea
IV tubing can be used for up to __ hours provided solution is continuously infusing through it.
- A. 34
- B. 72
- C. 25
- D. 7
Correct Answer: B
Rationale: The rationale is that IV tubing should be changed every 72 hours to prevent infection if the solution is continuously running.
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A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?
- A. Administer pain medication as ordered.
- B. Check the client's blood pressure.
- C. Place the client in a supine position.
- D. Increase the client's fluid intake.
Correct Answer: B
Rationale: The correct action is to check the client's blood pressure first. A sudden onset of pounding headache and blurred vision in a client with a spinal cord injury at T6 can indicate autonomic dysreflexia. Checking the blood pressure is crucial as autonomic dysreflexia can lead to severe hypertension, which can result in life-threatening complications such as stroke or seizure. Immediate assessment and intervention are necessary to prevent further harm. Administering pain medication without addressing the underlying cause can exacerbate hypertension. Placing the client in a supine position can worsen symptoms, and increasing fluid intake does not address the immediate issue at hand. Therefore, checking the blood pressure is the priority to identify and manage autonomic dysreflexia effectively.
A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?
- A. Weight gain of 1 kg since the last dialysis session
- B. Blood pressure of 150/90 mm Hg
- C. Potassium level of 6.5 mEq/L
- D. Hemoglobin level of 10 g/dL
Correct Answer: C
Rationale: The correct answer is C: Potassium level of 6.5 mEq/L. High potassium levels in ESRD patients can lead to life-threatening cardiac arrhythmias. Immediate action is needed to prevent complications. A: Weight gain may indicate fluid retention, but it's not an immediate concern. B: Blood pressure is elevated but not an urgent issue. D: Hemoglobin level of 10 g/dL is within the acceptable range for ESRD patients and does not require immediate action.
How does the pain of a myocardial infarction (MI) differ from stable angina?
- A. Accompanied by shortness of breath
- B. Feelings of fear or anxiety
- C. Lasts about 3-5 minutes
- D. Relieved by taking nitroglycerin
Correct Answer: A
Rationale: The correct answer is A, as the pain of MI is often accompanied by shortness of breath due to decreased oxygen supply to the heart muscle, whereas stable angina typically does not present with this symptom. Shortness of breath in MI is due to the heart's inability to pump effectively. Choices B, C, and D are incorrect because feelings of fear or anxiety, duration of pain, and response to nitroglycerin are not definitive differentiating factors between MI and stable angina.
What is the rationale for using preoperative checklists on the day of surgery?
- A. The patient is correctly identified.
- B. All preoperative orders and procedures have been carried out and records are complete.
- C. Patients' families have been informed as to where they can accompany and wait for patients.
- D. Preoperative medications are the last procedure before the patient is transported to the operating room.
Correct Answer: B
Rationale: Checklists ensure all necessary steps are completed, enhancing patient safety.
A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height & weight
- D. Occupation & hobbies
Correct Answer: D
Rationale: The correct answer is D: Occupation & hobbies. This information is crucial as certain occupations or hobbies may expose the client to respiratory hazards, influencing their respiratory status. The healthcare professional needs to assess potential respiratory risks in the client's environment.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status assessment.
B: Neck circumference is more relevant for assessing risk of obstructive sleep apnea rather than overall respiratory status.
C: Height & weight are important for assessing overall health and potential respiratory issues like obesity, but not as immediate as assessing respiratory hazards in the client's daily activities.