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Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: B
Rationale: Nurse Aida and Roger are in the Orientation phase (B). This stage involves the first meeting, establishing a contract (meeting frequency, termination expectations), and initial assessments to set goals. Pre-Orientation (A) is before contact, reviewing records. Working (C) focuses on implementing plans, and Termination (D) ends the relationship. Orientation, per Peplau, sets the foundation with trust and planning, matching Aida's actions, making B correct.
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The nurse must verify the client's identity before administration of medication. Which of the following is the safest way to identify the client?
- A. Ask the client his name
- B. Check the client's identification band
- C. State the client's name aloud and have the client repeat it
- D. Check the room number
Correct Answer: B
Rationale: The ID band is the most reliable method, ensuring accuracy even if the client is confused.
Refers to the pressure when the ventricles are at rest
- A. Diastole
- B. Systole
- C. Preload
- D. Pulse pressure
Correct Answer: A
Rationale: Diastolic pressure is when ventricles rest e.g., 80 in 120/80 showing resistance. Systole (contraction), preload (filling), pulse pressure (difference) differ. Nurses measure this e.g., hypertension for health, per BP definitions.
During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply.
- A. Cortisol
- B. Thyroid
- C. Estrogen
- D. Testosterone
Correct Answer: B
Rationale: Increased BMR with elevated temperature suggests thyroid (B) excess (hyperthyroidism), boosting metabolism. Cortisol (A) affects stress, not BMR primarily. Estrogen (C) and testosterone (D) influence other systems. B is correct. Rationale: Thyroid hormones (T3, T4) directly raise BMR and heat, a classic endocrine imbalance, per physiology, unlike other hormones with indirect effects.
A client is receiving 115 ml/hr of continuous IVF. The nurse noticed that the venipuncture site was red and swollen. Which of the following interventions would the nurse perform first?
- A. Stop the infusion
- B. Call the attending physician
- C. Slow that infusion to 20 ml/hr
- D. Place a cold towel on the site
Correct Answer: A
Rationale: Stopping the infusion is the nurse's first intervention when observing a red, swollen venipuncture site, as this may indicate phlebitis, infiltration, or infection. Halting the IV prevents further tissue damage or fluid extravasation, prioritizing patient safety. Redness and swelling suggest inflammation or leakage into surrounding tissue, requiring immediate cessation to assess severity and plan next steps, like site relocation or physician consultation. Calling the physician follows assessment, not precedes stopping the infusion, as the nurse acts within scope to mitigate harm first. Slowing the infusion might worsen damage if fluid is already escaping the vein. A cold towel could reduce swelling later but doesn't address the active infusion causing the issue. Stopping the infusion is the critical initial step, enabling evaluation and preventing complications, aligning with nursing's focus on prompt, protective action.
A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending:
- A. Pulmonary egophony
- B. Amniotic fluid embolism
- C. Anaphylaxis
- D. Bronchospasm
Correct Answer: C
Rationale: Sudden breathing difficulty, weakness, and nausea during antibiotic administration suggest a severe allergic reaction, known as anaphylaxis. This life-threatening condition involves systemic histamine release, causing airway constriction, hypotension, and gastrointestinal distress. Pulmonary egophony relates to lung sound changes, not systemic symptoms. Amniotic fluid embolism presents with cardiovascular collapse and bleeding, not primarily nausea. Bronchospasm is airway narrowing but lacks the broader symptoms here. Immediate recognition of anaphylaxis prompts epinephrine administration and airway support, critical for maternal and fetal survival in labor.