Nokea
Mr. Gary refuses pork-based medication because of his religious belief. This is an example of?
- A. Culture
- B. Illness
- C. Disability
- D. Risk factor
Correct Answer: A
Rationale: Refusing pork-based meds due to religion is culture (A) beliefs shaping health choices, per cultural competence. Illness (B) is disease, disability (C) function loss, risk factor (D) predisposition not belief-based. A reflects how culture influences care decisions, making it correct.
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How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
- A. Draw up the NPH insulin, then the regular insulin, in the same syringe
- B. Draw up the regular insulin, then the NPH insulin, in the same syringe
- C. Use two separate syringes
- D. Check with the physician
Correct Answer: B
Rationale: Regular (clear) is drawn first, then NPH (cloudy), to avoid contamination.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth
- B. The medication will be needed throughout the child's lifetime
- C. The medication schedule can be arranged to allow for drug holidays
- D. The medication is given one time daily every other day
Correct Answer: B
Rationale: Lifetime thyroid hormone replacement is needed for congenital hypothyroidism to prevent developmental delays growth spurts, holidays, or alternate days don't suffice. Nurses reinforce this, ensuring adherence, critical for normal growth in this endocrine disorder.
Which of the following is more life threatening?
- A. BP=180/100
- B. BP=160/120
- C. BP=90/60
- D. BP=80/50
Correct Answer: D
Rationale: BP 80/50 is most life-threatening e.g., hypoperfusion risks failure vs. 180/100 (hypertension), 160/120 (severe), 90/60 (borderline). Nurses prioritize this e.g., fluids for stability, per hemodynamics.
When charting in the client's record or chart, the nurse most needs to do which one of the following things?
- A. Date and sign each entry.
- B. Chart every two hours.
- C. Use ballpoint pen and not pencil.
- D. Cross out errors so others can't read them.
Correct Answer: A
Rationale: Dating and signing each chart entry is most essential, establishing a legal timeline and accountability for actions. Fixed intervals aren't mandatory, pens ensure permanence but aren't the priority, and crossing out errors risks misinterpretation. This practice validates care, crucial for nursing documentation integrity.
The nurse is preparing to take vital signs in an alert client admitted with dehydration secondary to vomiting and diarrhea. What is the best method to assess the client's temperature?
- A. Oral
- B. Axillary
- C. Radial
- D. Heat sensitive tape
Correct Answer: B
Rationale: Axillary is safest and most accessible for a dehydrated client with GI issues, avoiding oral route due to vomiting and diarrhea.