Nokea
The BEST position for the patient to assume in case of shock is ______.
- A. modified Trendelenburg
- B. recumbent
- C. high Fowler's
- D. low Fowler's
Correct Answer: A
Rationale: The BEST position for a patient in shock is the modified Trendelenburg position. In this position, the patient's legs are elevated above the level of the heart to enhance blood flow back to the heart and vital organs. Placing the patient in the modified Trendelenburg position helps increase venous return, improves cardiac output, and promotes perfusion to vital organs, which can be crucial in managing shock. This position can help stabilize the patient's condition while awaiting further medical intervention.
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Nurse Roberto is aware that a client who has experienced cardiac arrest is MOST at risk for which of the following imbalances?
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: D
Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.
A patient receiving palliative care for end-stage liver cancer experiences severe nausea and vomiting despite antiemetic therapy. What should the palliative nurse consider when addressing the patient's symptoms?
- A. Increase the dosage of the current antiemetic medication.
- B. Switch to a different antiemetic medication with a different mechanism of action.
- C. Discontinue antiemetic therapy and explore non-pharmacological interventions.
- D. Administer intravenous fluids to alleviate dehydration associated with vomiting.
Correct Answer: B
Rationale: When a patient receiving palliative care for end-stage cancer experiences severe nausea and vomiting despite current antiemetic therapy, the palliative nurse should consider switching to a different antiemetic medication with a different mechanism of action. This approach is based on the concept of individual variability in response to medications, as well as the potential development of tolerance to a particular drug. Switching to a different antiemetic with a new mechanism of action can provide the patient with a fresh chance at better symptom control by targeting different receptors or pathways involved in nausea and vomiting. It is important to consult the healthcare team and consider the patient's overall condition and medication history before making any changes in the treatment plan.
A nurse is assessing a patient's pain using a pain rating scale. What action by the nurse demonstrates cultural competence in pain assessment?
- A. Assuming that the patient experiences pain similarly to other patients
- B. Using nonverbal cues to assess the patient's pain intensity
- C. Asking the patient about their cultural beliefs and preferences related to pain
- D. Administering pain medication without assessing the patient's pain level
Correct Answer: C
Rationale: Choosing option C, asking the patient about their cultural beliefs and preferences related to pain, demonstrates cultural competence in pain assessment. Pain experiences can vary greatly across different cultures, and a patient's cultural background can influence how they perceive and express pain. By inquiring about the patient's cultural beliefs and preferences, the nurse can gain a better understanding of the patient's perspective on pain. This information is crucial for providing individualized and culturally sensitive pain management interventions. It also shows respect for the patient's unique cultural background and helps build a trusting and collaborative relationship between the nurse and the patient.
You accidentally touch Claudia's eyelid during eye drop instillation causing her to blink. What should have you done to prevent this from occurring?
- A. Touch the inner side of the medicine cap
- B. Tilt back Claudia's head slightly
- C. Hold the dropper close to the eye but do not allow the medication to fall into the cornea
- D. Have Claudia look up and focus on something
Correct Answer: B
Rationale: Tilt back Claudia's head slightly would have been the correct action to prevent her from blinking during eye drop instillation. By tilting her head back, you create a more stable position for instilling the eye drops, reducing the likelihood of accidental contact with her eyelid. Additionally, tilting the head back slightly helps in making it easier for the drops to enter the eye and stay within the conjunctival sac, improving the efficacy of the medication.
In handling all information about the famiilies in the community, which of the following principles should the nurse consider ethical?
- A. Confidentialty
- B. Justice
- C. Fair treatment
- D. Beneficence
Correct Answer: A
Rationale: When handling information about families in the community, the nurse should consider the principle of confidentiality as ethical. Confidentiality refers to the obligation of healthcare providers to safeguard the privacy of patient information. By maintaining confidentiality, the nurse upholds trust and respect in the nurse-family relationship. This principle ensures that sensitive information shared by families is kept secure and not disclosed without permission, thus respecting their autonomy and promoting open communication in healthcare settings.