Nokea
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?
- A. I will take salt tablets when I work outdoors in the summer.
- B. I should take acetaminophen (Tylenol) if I start to feel too warm.
- C. I should drink sports drinks when working outside in hot weather.
- D. I will move to a cool environment if I notice that I am feeling confused.
Correct Answer: C
Rationale: The correct answer is C: "I should drink sports drinks when working outside in hot weather." This statement is correct because hypotension and elevated temperature could indicate dehydration and electrolyte imbalance due to excessive sweating in hot weather. Drinking sports drinks can help replenish electrolytes lost through sweating and prevent dehydration.
Incorrect choices:
A: Taking salt tablets can lead to an imbalance in electrolytes and worsen the condition.
B: Acetaminophen can lower fever but does not address dehydration or electrolyte imbalance.
D: Moving to a cool environment when feeling confused is important but does not address the underlying issue of dehydration and electrolyte imbalance.
You may also like to solve these questions
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
- A. Assess the patient’s current vital signs.
- B. Give acetaminophen (Tylenol) per agency protocol.
- C. Ask the patient to provide clean-catch urine for urinalysis.
- D. Tell the patient that it will be 1 to 2 hours before being seen by the doctor.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention.
The other choices are incorrect because:
B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment.
C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case.
D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
The American Nurses Credential Center Magnet Recognition Program supports many actions to ensure that nurses are engaged and empowered to participate in ethical decision making. Which of the following would assist nurses in being involvabeirdb .icnom r/etesset arch studies?
- A. Education on protection of human subjects
- B. Participation of staff nurses on ethics committees
- C. Written descriptions of how nurses participate in ethic s programs
- D. Written policies and procedures related to response to ethical issues
Correct Answer: A
Rationale: Rationale:
A: Education on protection of human subjects is crucial for nurses to understand ethical principles when conducting research studies. It ensures compliance with ethical guidelines and protection of research participants.
B: Participation of staff nurses on ethics committees is not directly related to conducting research studies and may not specifically involve protection of human subjects.
C: Written descriptions of how nurses participate in ethics programs do not necessarily focus on research studies and may not cover the specific ethical considerations required in research.
D: Written policies and procedures related to response to ethical issues are important but may not provide the necessary knowledge on protection of human subjects for conducting research studies.
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
- A. Use tweezers to remove any remaining ticks.
- B. Check the vital signs, including temperature.
- C. Give doxycycline (Vibramycin) 100 mg orally.
- D. Obtain information about recent outdoor activities.
Correct Answer: A
Rationale: The correct answer is A: Use tweezers to remove any remaining ticks. The first step is to remove the tick to prevent further transmission of any potential pathogens. This is crucial in preventing tick-borne illnesses. Checking vital signs (B) can be done after the tick is removed. Administering doxycycline (C) should be based on guidelines and individual factors. Obtaining information about recent outdoor activities (D) is important but not the immediate priority.
The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best be implemented to facilitate famil y-centered care?
- A. Ensuring that the patient’s room is large enough to inc lude a sleeper sofa and storage for family members’ personal belongings.
- B. Including a diagnostic suite in close proximity to the u nit so that the patient does not have to travel far for testing.
- C. Incorporating a large waiting room on the top floor of athbierb .hcooms/pteistta l with a scenic view and amenities such as coffee and tea.
- D. Providing access to a scenic garden for meditation.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Family-centered care promotes involvement of family members in patient care.
2. A sleeper sofa in the patient's room allows family members to stay overnight, enhancing support for the patient.
3. Storage for personal belongings ensures families can have essentials close by, increasing comfort and convenience.
4. These design elements facilitate family presence, communication, and participation in care, aligning with family-centered care principles.
Summary of Incorrect Choices:
B. Having a diagnostic suite nearby is convenient but not directly related to family-centered care principles.
C. A waiting room with amenities is beneficial but does not directly involve families in patient care.
D. Access to a garden for meditation is helpful for relaxation but does not emphasize family involvement in care.
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
- A. Palpate extremities for bilateral pulses.
- B. Observe the patient’s respiratory effort.
- C. Check the patient’s level of consciousness.
- D. Examine the patient for any external bleeding.
Correct Answer: B
Rationale: Rationale: The correct action is to observe the patient's respiratory effort next. This step ensures that the patient's breathing remains stable and adequate. If respiratory effort is compromised, immediate intervention is required. Checking for bilateral pulses (A) is important but comes after ensuring respiratory status. Checking level of consciousness (C) is also crucial but not as immediate as monitoring breathing. Examining for external bleeding (D) is important but not the priority when airway and breathing are already determined to be clear.