Nokea
Tom reports abdominal pain that started over the periumbilical area and moved to the right lower quadrant area. Tom probably has
- A. Crohn's disease.
- B. Cholecystitis.
- C. Appendicitis.
- D. Diverticulitis.
Correct Answer: C
Rationale: Appendicitis typically presents with migrating pain from the periumbilical area to the right lower quadrant.
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What condition should the nurse anticipate that might occur during epidural and spinal anesthesia?
- A. Spinal headache
- B. Hypotension and bradycardia
- C. Loss of consciousness and seizures
- D. Downward extension of nerve block
Correct Answer: B
Rationale: Epidural and spinal anesthesia commonly cause hypotension and bradycardia due to sympathetic blockade.
The charge nurse assigned the care of a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegate to the nursing assistant? (Choose all that apply.)
- A. Provide oral care every 3-4 hours
- B. Monitor for indications of dehydration
- C. Administer 0.45% saline by IV line
- D. Assess daily weights for trends
Correct Answer: A
Rationale: Oral care and assessing daily weights are tasks that can be delegated to a nursing assistant. Monitoring for dehydration and administering IV fluids require more advanced clinical skills.
Which drainage is drained with a Hemovac?
- A. Bile
- B. Urine
- C. Gastric contents
- D. Wound drainage
Correct Answer: D
Rationale: Hemovacs are used for wound drainage, collecting serosanguinous fluid.
Mary, who is scheduled for a thoracentesis, asks why there is so much fluid in the pleural space. You respond by saying
- A. Your body is unable to remove fluid, resulting in a buildup of fluid in the pleural space around your lungs.
- B. An error occurred and you were administered too much IV medication.
- C. This is the result of oxygen therapy.
- D. This is a normal side effect of bumetanide, which is medication ordered by your physician.
Correct Answer: A
Rationale: Fluid accumulation in the pleural space can occur due to various conditions like heart failure or infection.
Which of the following is the priority nursing diagnosis?
- A. Risk for Infection related to organisms specific to cat bites
- B. Impaired Skin Integrity related to puncture wounds
- C. Ineffective Health Maintenance related to immunization status
- D. Risk for Impaired Mobility related to potential tendon damage
Correct Answer: A
Rationale: Cat bites carry a high risk of infection due to the bacteria present in their mouths.