Nokea
Ms. L had a C-section done. She delivered a healthy baby boy. On her 1st post operative day, Ms. L's roommate called the nurse & reports that Ms. L was very anxious & pale looking. Other clients were in Ms. L's room trying to help out. Upon assessment, her BP was 80/60, HR 110bpm.
The top nursing priority includes:
- A. monitor the patient's v/s & notify the doctor stat
- B. Clear the patient's immediate environment & ask other clients to move away
- C. Place the patient in flat position and check her abdominal dressing.
- D. Get the crash cart in anticipation for cardiac arrest
Correct Answer: A
Rationale: Hypotension and tachycardia suggest postpartum hemorrhage, requiring immediate physician notification.
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A client's vision is to be evaluated using the Ishihara exam. The nurse recognizes that the client will be checked for:
- A. Macular degeneration
- B. Astigmatism
- C. Color blindness
- D. Glaucoma
Correct Answer: C
Rationale: The Ishihara exam tests for color blindness by assessing color perception. It does not evaluate macular degeneration, astigmatism, or glaucoma.
A young female patient comes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis.
When obtaining information from the patient, the nurse would expect her to report that:
- A. Her level of fatigue has been constant.
- B. The longer she rests the weaker she feels.
- C. Her strength increases with progressive activity.
- D. The symptoms seem more severe in the evening.
Correct Answer: D
Rationale: Myasthenia gravis symptoms worsen with activity and are more severe in the evening due to muscle fatigue.
A client with dumping syndrome should ___ while a client with GERD should ___
- A. sit up 1 hour after meals; lie flat 30 minutes after meals
- B. lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. sit up after meals; sit up after meals
- D. lie down after meals; lie down after meals
Correct Answer: B
Rationale: Lying down after eating slows gastric emptying, reducing dumping syndrome symptoms. Sitting up prevents acid reflux in GERD. The other combinations are incorrect for these conditions. Basic Care and Comfort
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest is the highest priority due to potential for pneumothorax or mediastinal shift, which can be life-threatening. The ABC (airway, breathing, circulation) principle prioritizes this injury. Physiological Adaptation
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.