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The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In this scenario, the nurse failed to assess the patient's condition promptly after being informed of feeling dizzy and light-headed. Assessment involves collecting data to identify actual or potential health problems. By not promptly assessing the patient's worsening condition, the nurse missed an essential step in the nursing process.
Choice B: Diagnosis comes after assessment and involves identifying the patient's health problems based on collected data. Choice C: Implementation is the phase where the nurse carries out the plan of care. Choice D: Evaluation occurs after implementation to determine if the interventions were effective.
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Hyperparathyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
- A. Heat intolerance and systolic
- B. Diastolic hypertension and widened hypertension pulse pressure
- C. Weight gain and heat intolerance
- D. Anorexia and hyper-excitability
Correct Answer: A
Rationale: The correct answer is A because hyperparathyroidism is not caused by increased levels of thyroxine but by overactivity of the parathyroid glands. This would lead to symptoms of heat intolerance due to increased metabolism and systolic hypertension due to the effects of excess parathyroid hormone on calcium levels.
Choice B is incorrect because diastolic hypertension and widened pulse pressure are not typical symptoms of hyperparathyroidism. Choice C is incorrect because weight gain is not a common symptom of hyperparathyroidism. Choice D is incorrect because anorexia and hyper-excitability are not typical symptoms of hyperparathyroidism.
A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:
- A. Maintain standard precautions
- B. Prepare for the possibility that the baby may be delivered by CS.
- C. Notify the obstetrician and nurse midwife about the vesicles as soon as possible.
- D. Apply antibiotic ointment to the vesicles and place the mother in reverse isolation
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor.
2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences.
3. Standard precautions should always be maintained to prevent the spread of infections.
4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.
An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: C
Rationale: Upon arrival, checking the lungs for equal breath sounds bilaterally is the first action. This is crucial to assess airway patency and breathing effectiveness in a patient with a history of diving accident and intubation. Ensuring proper oxygenation takes precedence over other actions. Taking vital signs, inserting an IV line, and performing a neurologic check can wait until airway and breathing are adequately assessed.
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications.
Summary:
A: Lungs - Not directly affected by potassium levels.
B: Liver - Not directly affected by potassium levels.
C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.
A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?
- A. Comply with the timing of antiviral medication around meals
- B. Avoid exposure to harsh sunlight for about 2hrs after taking the medication
- C. Have the medications with plenty of fruit juice
- D. Have an increased dose of the medications if the symptoms worsen
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Timing: Antiviral medications should be taken as prescribed to maintain consistent drug levels in the body.
2. Around meals: Taking medications with or without food can affect absorption, so timing around meals helps with consistency.
3. Compliance: Following the timing instructions increases medication effectiveness and reduces the risk of drug resistance.
Other Choices:
B) Avoiding harsh sunlight: Not directly related to medication administration; may be a precaution for other reasons.
C) Having medications with fruit juice: This is not a standard instruction for antiviral medications; may not be suitable for all medications.
D) Increasing dose for worsening symptoms: This is dangerous and should only be done under healthcare provider supervision; self-adjusting medication doses can be harmful.