Nokea
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
- A. Trendelenburg
- B. Prone
- C. Semi-Fowlers
- D. Side-lying with head flat
Correct Answer: C
Rationale: Semi-Fowlers. Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion, helping to manage increased intracranial pressure.
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Most asthmatic attacks respond to Epinephrine (Adrenalin)
Most asthmatic attacks respond to Epinephrine (Adrenalin) and it may be used as a therapeutic agent in the treatment of some allergic conditions because it:
- A. Improves cardiac output due to its positive inotropic effect.
- B. Acts as a hypertensive agent elevating BP.
- C. Dilates the bronchi.
- D. Antagonizes histamine.
Correct Answer: C
Rationale: Epinephrine dilates bronchi, relieving bronchospasm in asthma and allergic reactions.
A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?
- A. Keep the infant NPO for two hours before the treatment.
- B. Ask the mother to stay away from the infant during the treatment.
- C. Monitor the client's pulse rate very carefully.
- D. Cover the baby's eyes during the treatment.
Correct Answer: D
Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.
The nurse is caring for a client with a history of chronic kidney disease who is receiving hemodialysis. Which of the following findings would require immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Weight gain of 1 kg since last dialysis.
- C. Bright red blood in the dialysis tubing.
- D. Potassium level of 4.5 mEq/L.
Correct Answer: C
Rationale: Bright red blood in the dialysis tubing indicates a potential access site bleed or tubing disconnection, requiring immediate intervention to prevent blood loss. Mild hypertension (A) and weight gain (B) are common, and a normal potassium level (D) is unremarkable.
Priority nursing diagnosis on the patient who was admitted with acute renal failure
Priority nursing diagnosis on the patient who was admitted with acute renal failure would be:
- A. Bed rest to conserve oxygen.
- B. Increase fluid intake to promote urination.
- C. Fatigue due to altered nutrition.
- D. Dehydration secondary to diuresis.
Correct Answer: C
Rationale: Fatigue due to altered nutrition is a priority in acute renal failure as it reflects metabolic imbalances and nutritional deficits.
Which of the following findings is most typical of a client with a fractured hip?
- A. Pain in the hip and affected leg
- B. Diminished sensation in the affected leg
- C. Absence of pedal and femoral pulses in the affected extremity
- D. Disalignment of the affected extremity
Correct Answer: A
Rationale: Pain in the hip and leg is the most typical symptom of a hip fracture. Diminished sensation, absent pulses, or disalignment may occur but are less common.