Nokea
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.
You may also like to solve these questions
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action?
- A. Diminished breath sounds over left lung field
- B. Localized pain at catheter insertion site
- C. Measured central venous pressure of 5 mm Hg
- D. Slight bloody drainage around insertion site
Correct Answer: A
Rationale: The correct answer is A: Diminished breath sounds over the left lung field. This finding could indicate a pneumothorax, a serious complication of subclavian CVC insertion. Immediate action is required to prevent respiratory distress.
Incorrect answers:
B: Localized pain at insertion site is common post-procedure and may not indicate a serious issue.
C: A central venous pressure of 5 mm Hg is within the normal range and does not require immediate action.
D: Slight bloody drainage is expected initially and can be managed with routine care.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
- A. Tracheostomy tube suctioning.
- B. Medication administration.
- C. Colostomy care instruction.
- D. Client personal hygiene.
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.
The nurse is preparing to administer atropine, an anticholinergic, to a client scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide?
- A. Provide a more rapid induction of anesthesia.
- B. Induce relaxation before induction of anesthesia.
- C. Decrease the risk of bradycardia during surgery.
- D. Minimize the amount of analgesia needed postoperatively.
Correct Answer: C
Rationale: The correct answer is C: Decrease the risk of bradycardia during surgery.
Rationale:
1. Atropine is an anticholinergic medication that works by blocking the parasympathetic nervous system.
2. During surgery, the parasympathetic stimulation can lead to bradycardia (slow heart rate).
3. By administering atropine, the nurse can counteract the bradycardic effects and maintain a normal heart rate during the procedure.
4. Options A, B, and D are incorrect as atropine is not used for inducing anesthesia, relaxation, or minimizing postoperative analgesia.
When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment?
- A. Central venous pressure (CVP)
- B. Systemic vascular resistance (SVR)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The correct answer is C: Pulmonary vascular resistance (PVR). PVR is the most appropriate parameter to monitor in a patient with pulmonary hypertension as it directly reflects the resistance in the pulmonary circulation. A decrease in PVR indicates a reduction in the constriction of blood vessels in the lungs, suggesting improvement in pulmonary hypertension. Monitoring CVP (A) is more relevant in assessing fluid status, SVR (B) is more indicative of systemic vascular tone, and PAWP (D) is useful in assessing left-sided heart function, but they are not as specific to evaluating the effectiveness of treatment for pulmonary hypertension.
What risk is the rationale for the recommendation of endot racheal rather than nasotracheal intubation?
- A. Basilar skull fracture
- B. Cervical hyperextension
- C. Impaired ability to "mouth" words
- D. Sinusitis and infection
Correct Answer: A
Rationale: The correct answer is A: Basilar skull fracture. Endotracheal intubation is recommended over nasotracheal intubation to avoid the risk of further damaging a basilar skull fracture. Nasotracheal intubation can potentially cause further injury due to the passage of the tube through the nasal cavity, which could exacerbate a basilar skull fracture.
Summary of other choices:
B: Cervical hyperextension - Not directly related to the choice between endotracheal and nasotracheal intubation.
C: Impaired ability to "mouth" words - Not a significant factor in determining the choice of intubation method.
D: Sinusitis and infection - While nasotracheal intubation can potentially lead to sinusitis and infection, the primary concern in this scenario is the risk of aggravating a basilar skull fracture.