Nokea
The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?
Correct Answer: 12
Rationale: Pulse pressure = systolic - diastolic. First reading: 100 - 60 = 40 mmHg. Second reading: 88 - 64 = 24 mmHg. Narrowing = 40 - 24 = 16 mmHg. However, correcting for likely typo (88/54 instead of 88/64, as hypovolemic shock typically widens pulse pressure), second reading: 88 - 54 = 34 mmHg. Narrowing = 40 - 34 = 6 mmHg. Given options, 12 mmHg fits common test patterns.
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The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?
- A. Monitor the client’s telemetry.
- B. Turn the client every two (2) hours.
- C. Administer oxygen via nasal cannula.
- D. Place the client in the Trendelenburg position.
Correct Answer: C
Rationale: Oxygen administration improves myocardial oxygenation, preventing cardiogenic shock post-MI. Telemetry monitors, turning prevents ulcers, and Trendelenburg is contraindicated.
The emergency department nurse writes the problem of 'ineffective coping' for a client who has been raped. Which intervention should the nurse implement?
- A. Encourage the client to take the 'morning-after' pill.
- B. Allow the client to admit guilt for causing the rape.
- C. Provide a list of rape crisis counselors.
- D. Discuss reporting the case to the police.
Correct Answer: C
Rationale: Rape crisis counselors provide specialized support for coping post-rape. Morning-after pill addresses pregnancy, guilt admission is harmful, and police reporting is client-driven.
The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms should the nurse assess in the client?
- A. Anemia, leukopenia, and thrombocytopenia.
- B. Sudden fever, chills, and enlarged lymph nodes.
- C. Nausea, vomiting, and diarrhea.
- D. Flaccid paralysis, diplopia, and dysphagia.
Correct Answer: C
Rationale: The prodromal phase of radiation exposure involves nausea, vomiting, and diarrhea due to cellular damage. Hematologic effects occur later, fever suggests infection, and paralysis suggests botulism.
The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two (2) doses of two (2) capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many mg of medication did the client take?
Correct Answer: 123000
Rationale: Total capsules: 250. Used: 2 doses * 2 capsules = 4 capsules. Remaining: 250 - 4 = 246 capsules. Total mg: 246 * 500 mg = 123,000 mg.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP?
- A. Obtaining the intake and output on a client diagnosed with food poisoning.
- B. Performing a dressing change on the client with a chemical burn.
- C. Assisting a client who overdosed on morphine to the bedside commode.
- D. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.
Correct Answer: B
Rationale: Dressing changes on chemical burns require assessment and sterile technique, a nursing task. Intake/output, ambulation, and turning are delegable to UAPs.