During CPR, which of the following actions should be performed immediately after activating the emergency response system?
- A. Start chest compressions.
- B. Check for breathing.
- C. Perform abdominal thrusts.
- D. Assess pulse.
Correct Answer: A
Rationale: After activating the emergency response system, the immediate priority in CPR is to begin chest compressions to support blood circulation. High-quality chest compressions are crucial in providing oxygen to vital organs, especially the brain, during cardiac arrest. Starting chest compressions promptly can improve the chances of survival for the person in need of CPR. Checking for breathing, performing abdominal thrusts, or assessing pulse should only be done after initiating chest compressions in the CPR sequence.
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Which of the following is a primary consideration in planning for her care?
- A. To prevent problems related to immobility
- B. To prevent infection
- C. Planning for client`s eventual inability communicate
- D. To prevent complications
Correct Answer: A
Rationale: When planning for a client's care, a primary consideration is to prevent problems related to immobility. Immobility can lead to a range of complications such as pressure ulcers, muscle weakness, joint contractures, and decreased circulation. To maintain the client's overall health and well-being, it is essential to address mobility issues and implement strategies to prevent complications associated with immobility. By prioritizing interventions that promote movement and prevent immobility-related problems, the client's quality of life can be improved and potential health risks mitigated.
What specific term should Nurse Gladys write in her charting when a patient is suffering from a change in the angle between the nail base greater than 180 degrees due to congenital heart disease?
- A. Peripheral neuropathy
- B. Inflammation of the fingers
- C. Peripheral cyanosis
- D. Clubbing of the fingers
Correct Answer: D
Rationale: Clubbing of the fingers is a specific term that Nurse Gladys should write in her charting when a patient is suffering from a change in the angle between the nail base greater than 180 degrees due to congenital heart disease. Clubbing of the fingers is a diagnostic sign associated with various medical conditions, including congenital heart disease. It is characterized by changes in the angle and shape of the nails, typically involving softening of the nail bed, enlargement of the fingertips, and a loss of the normal angle between the nail and the nail bed. Peripheral neuropathy, inflammation of the fingers, and peripheral cyanosis are different conditions and do not specifically describe the nail changes seen in clubbing.
A patient was for transfer to a tertiary hospital because of severe asthma, but the nurse do not prepare the patient right away and the patient dies. Which of the following the nurse is liable?
- A. Malpractice
- B. Murder
- C. Assault
- D. Battery
Correct Answer: A
Rationale: In this scenario, the nurse's failure to promptly prepare the patient for transfer to a tertiary hospital resulted in the patient's death. This situation falls under the category of malpractice, which refers to professional negligence or failure to provide a standard level of care that results in harm to a patient. The nurse had a duty to ensure the patient's timely transfer and by delaying the necessary actions, the nurse failed to uphold this duty, leading to a tragic outcome. Murder, assault, and battery are criminal offenses that do not fit the circumstances described in the scenario.
Nurse Mary randomly seleted individuals in the community who will be part of a project. Which of the following ethical principle is observed by the nurse?
- A. Autonomy
- B. Confidentiality
- C. Beneficence
- D. Fair treatment
Correct Answer: A
Rationale: By randomly selecting individuals in the community for the project, Nurse Mary is upholding the ethical principle of autonomy. Autonomy refers to respecting individuals' right to make their own decisions and choices. In this scenario, Nurse Mary is not imposing her own preferences or biases but rather allowing individuals in the community to have an equal opportunity to participate in the project. Random selection ensures that the process is fair and gives everyone an equal chance to be involved, respecting their autonomy.
A postpartum client reports severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Assessing blood pressure and other vital signs
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to assess the client's blood pressure and other vital signs. The client's symptoms of severe headache, visual disturbances, and epigastric pain could be indicative of preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Checking the blood pressure and other vital signs will help determine if the client's symptoms are related to abnormal blood pressure levels, which is critical in identifying and managing hypertensive disorders in postpartum clients. Once the assessment is completed, appropriate medical interventions can be initiated promptly if necessary.