Nokea
List the order in which you will assess these patients.
- A. An ambulatory, dazed 25-year-old male with a bandaged head wound
- B. An irritable infant with a fever, petechiae, and nuchal rigidity
- C. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
- D. A 50-year-old female with moderate abdominal pain and occasional vomiting
Correct Answer: B
Rationale: The infant with fever, petechiae, and nuchal rigidity may indicate meningitis, a life-threatening condition requiring immediate attention.
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For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
- A. Impaired skin integrity related to incision
- B. Impaired mobility related to decreased muscle strength
- C. Risk for aspiration related to decreased muscle strength
- D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D
Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.
You are caring for a patient who has had a transurethral resection of the prostate for benign prostatic hypertrophy. There is continuous bladder irrigation setup. You would notify the physician if you noted
- A. Any signs of hematuria.
- B. A change from clear red output to thicker, bright red output.
- C. A decrease in the amount of blood in the urine.
- D. The development of uremic pruritis.
Correct Answer: B
Rationale: Thicker, bright red output indicates potential bleeding requiring medical attention.
Which of the following is a finding that is most often associated with endometrial cancer?
- A. Thickened endometrial lining on ultrasound
- B. Irregular periods
- C. Young age
- D. Dyspareunia
Correct Answer: A
Rationale: A thickened endometrial lining on ultrasound is commonly associated with endometrial cancer, indicating abnormal cell growth.
A patient is brought into the ER. The patient's BAL is 0.48 and the patient is unconscious. What is the first thing you do?
- A. Place the patient in a quiet area and wait until the patient begins to sober before continuing your assessment.
- B. Call the ED practitioner immediately.
- C. Administer Narcan to the patient.
- D. Send the patient to ICU immediately.
Correct Answer: B
Rationale: Immediate notification of the ED practitioner ensures prompt intervention for a life-threatening condition.
What strategies could decrease the distress of rotating shifts for nurses (select all that apply)?
- A. Take a brief onsite nap
- B. Use sleep hygiene practices
- C. Sleep just before going to work
- D. Maintain consistent sleep/wake schedules even on days off (if possible)
Correct Answer: A
Rationale: The correct answers are A, B, and D. Brief naps (A), sleep hygiene (B), and consistent schedules (D) improve adaptation to shift work. Sleeping just before work (C) can worsen sleep quality.