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The nurse is arriving at the beginning of her shift and has taken report on four clients on a medical surgical unit. Which client should the nurse see first?
- A. A Client with pyelonephritis with nausea and vomiting
- B. A client with chronic obstructive pulmonary disease with an oxygen saturation of $90 \%$ on room air
- C. A client post vaginoplasty with bright red blood and clots in her catheter
- D. A client post-total abdominal hysterectomy with 9/10 pain
Correct Answer: C
Rationale: Bright red blood and clots post-vaginoplasty scream hemorrhage ABCs prioritize circulation, needing instant check for shock or transfusion. Pyelonephritis nags, COPD's stable at 90\%, pain's urgent but not bleeding. Nurses hit bleeding first, a life-line call in this post-op rush.
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An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
- A. Apply an ice pack or heating pad PRN to relieve pain and pruritis
- B. Avoid skin contact with water whenever possible
- C. Apply phototherapy PRN
- D. Avoid rubbing or scratching the affected area
Correct Answer: D
Rationale: Radiation erythema's tender rubbing or scratching tears it open, risking infection. Ice or heat burns it worse; water's fine for gentle cleaning, not avoidance. Phototherapy's for jaundice, not this. Nurses push hands off' to protect radiated skin, a staple in oncology to heal without added damage.
Which of the following statements regarding weight regulation is FALSE?
- A. Functional MRI (fMRI) studies have shown overactivation of reward-encoding brain regions and/or deficiency in cortical inhibitory networks in obese people
- B. The homeostatic weight regulation circuitry centres around the corticolimbic structures of the brain
- C. Liking and wanting of food are subconscious processes
- D. The reward system of weight regulation is nonhomeostatic in nature
Correct Answer: B
Rationale: Weight regulation involves homeostatic (hypothalamic) and nonhomeostatic (reward-driven) systems. fMRI studies showing reward region overactivation in obesity, subconscious liking/wanting, and the reward system's nonhomeostatic nature are true. However, homeostatic regulation centers on the hypothalamus, not corticolimbic structures (involved in reward/emotion), making this false. Understanding this distinction aids physicians in addressing both physiological and behavioral drivers in chronic obesity management.
A nurse is caring for a client who was received in the emergency department with a heart rate of 220 beats per minute. The client's cardiac monitor displays supraventricular tachycardia (SVT). Which of the following interventions should the nurse anticipate?
- A. Apply compression stockings
- B. Perform Valsalva maneuver
- C. Draw labs
- D. Check blood glucose
Correct Answer: B
Rationale: SVT's 220 bpm blitz needs breaking Valsalva maneuver, bearing down, jolts the vagus nerve, slowing rate, a first-line trick. Stockings aid veins, not rhythm. Labs or glucose inform, don't fix. Nurses anticipate this, calming tachycardia, a quick, non-invasive hit in this racing heart emergency.
A community health center is preparing a presentation on the prevention and detection of cancer. Which health care professional should be assigned to address the topic: Explain screening exams and diagnostic testing for common cancers?
- A. RN
- B. LPN/LVN
- C. Nurse Practitioner
- D. Nutritionist
Correct Answer: C
Rationale: Explaining screening exams and diagnostic testing for cancers like mammograms or colonoscopies requires advanced knowledge of procedures, interpretation, and patient counseling, fitting the nurse practitioner's role. NPs perform exams, order diagnostics, and educate on results, bridging clinical and teaching skills in community settings. RNs focus on care coordination and basic education, not diagnostics. LPN/LVNs handle practical tasks, lacking authority for in-depth screening discussions. Nutritionists address diet, not testing protocols. NPs' expertise ensures accurate, authoritative delivery, critical for empowering attendees with prevention knowledge, aligning with their scope in primary care and health promotion initiatives.
In caring for a patient with neutropenia, what tasks can be delegated to the nursing assistant?
- A. Take vital signs every 4 hours
- B. Report temperature elevation >100.4°F
- C. Assess for sore throat, cough, or burning with urination
- D. Gather the supplies to prepare the room for protective isolation
Correct Answer: A
Rationale: Neutropenia heightens infection risk, requiring team vigilance. Taking vital signs every 4 hours fits nursing assistants' scope routine monitoring flags fevers, key in neutropenia, without needing assessment skills. Reporting fever >100.4°F is their duty once detected, but assessing symptoms like sore throat or cough demands RN judgment to interpret infection signs. Gathering supplies for isolation is assistive, not evaluative, suiting their role. Handwashing's universal, not a task to delegate. Vital signs delegation ensures timely data collection, freeing nurses to analyze and act, a practical split in caring for this vulnerable patient.