Number the priority of the following conditions using the numbers # 1 through # 6 with # 1 as the greatest priority and # 6 as the least priority. 1. Atrial fibrillation 2. First degree heart block 3. Shortness of breath upon exertion 4. An obstructed airway 5. Fluid needs 6. Respect and esteem by others
- A. 3,4,2,1,5,6
- B. 3,4,5,1,2,6
- C. 2,3,5,1,4,6
- D. 3,2,4,1,5,6
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework and Maslow's hierarchy, the correct order is: An obstructed airway (4, #1, life-threatening), Shortness of breath upon exertion (3, #2, breathing issue), Fluid needs (5, #3, physiological need), Atrial fibrillation (1, #4, potential circulatory issue), First degree heart block (2, #5, often asymptomatic), Respect and esteem by others (6, #6, psychological need). Thus, B (3,4,5,1,2,6) is correct.
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A client with a history of gout is prescribed febuxostat (Uloric). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Febuxostat can cause hepatotoxicity, requiring liver function monitoring.
The sense of hearing is assessed using which standardized test?
- A. The Taylor test
- B. The Rinne test
- C. The Babinski test
- D. The APGAR test
Correct Answer: B
Rationale: The Rinne test is a standardized test used to assess hearing by comparing air and bone conduction using a tuning fork.
You are the Assistant Director of Nursing in a multi ethnic and culturally diverse inner city acute care facility. You will be chairing a committee to develop a philosophy of nursing that addresses these facility characteristics and the characteristics of the clients. Which theoretical framework would you recommend that this committee should consider when addressing multi ethnicity and the culturally diverse nature of this facility for this philosophy?
- A. Jean Watson's
- B. Martha Rogers'
- C. Nagi's theory
- D. Madeleine Leininger's theory
Correct Answer: D
Rationale: Madeleine Leininger's theory of Transcultural Nursing focuses on providing culturally congruent care, making it the most appropriate framework for addressing the needs of a multi-ethnic and culturally diverse population.
The nurse is beginning the shift and is now responsible for the following clients on the postpartum unit and has not yet made rounds on the clients. Additionally, the nurse is responsible for three other clients who are currently listed as stable. The nurse will also be getting a new admission in 15 minutes. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first?
- A. The three clients who are reported to be stable.
- B. The mother with a 4-hour-old infant with initial blood glucose of 33 mg\dL and now at 15 mg/dL.
- C. A mother who had a spontaneous vaginal delivery (SVD) client and received methylergonovine maleate (Methergine) 1 hour ago for increased bleeding.
- D. A mother with a 3-day-old who had a bilirubin level of 13 mg\dL 30 minutes ago, and is now in a 'bili blanket' at the mother's bedside.
Correct Answer: B
Rationale: The infant with a blood glucose of $15 \mathrm{mg} / \mathrm{dL}$ is critically low, indicating severe hypoglycemia, which requires immediate intervention to prevent neurological damage.
A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?
- A. Add the client's daughter to serve as an interpreter.
- B. Ask one of the Hispanic nursing assistants to serve as an interpreter.
- C. Use the limited Spanish learned in high school along with nonverbal communication.
- D. Obtain a trained medical interpreter.
Correct Answer: D
Rationale: A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the client's confidentiality. Using the nursing assistant or limited Spanish and nonverbal communication reduces the accuracy of interpretation and back-translation into English.
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