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What action should the nurse take?
- A. Reassure patient that pain is normal following surgery.
- B. Administer pm Nifedipine and assess client's response.
- C. Administer pm Meperidine HCL and assess client's response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct Answer: C
Rationale: A sinus tachycardia is a physiological response to pain. Treating the cause of the increased pulse rate requires pain medication.
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A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first?
- A. Check the patient's chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screen on the patient.
- D. Request the physician on-call assess the patient.
Correct Answer: B
Rationale: Dizziness can be a sign of hypotension, that may a contraindication with Morphine.
Which of the following is one of the main goals for Healthy People 2010?
- A. reduction of health care costs
- B. elimination of health disparities
- C. investigation of substance abuse
- D. determination of an acceptable morbidity rate
Correct Answer: B
Rationale: Healthy People 2010 has as its main goal elimination of health disparities among the U.S. population. Healthy People 2010 is a set of health objectives for the nation to achieve over the first decade of the twenty-first century and was developed by the Surgeon General's office. Earlier editions of this report, Healthy People and Healthy People 2000: National Health Promotion and Disease Prevention Objectives established national health objectives and served as the basis for the development of state and community plans.
A 50 milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
- A. 100 ml per hour for one hour.
- B. 60 ml per hour for one-half hour.
- C. 120 ml per hour for one hour.
- D. 50 ml per hour for one hour.
Correct Answer: A
Rationale: One hundred ml in one hour equals 50 ml in 30 minutes, which is what the physician prescribed. Choice 2 is 10 ml more than the physician prescribed for 30 minutes. Choice 3 is the same as Choice 2; it is 10 ml more than the physician prescribed for 30 minutes. Choice 4 only provides 25 ml over 30 minutes, or half the volume prescribed.
A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition?
- A. An inflammatory process of the extrahepatic bile ducts
- B. An arrest of the normal flow of bile
- C. An inflammation of the gallbladder
- D. The formation of gallstones
Correct Answer: B
Rationale: Cholestasis from TPN is an intrahepatic interruption of bile flow, unlike cholangitis (duct inflammation), cholecystitis (gallbladder inflammation), or gallstone formation.
A client asks the nurse what risk factors increase the chances of getting skin cancer. The risk factors include all except:
- A. Light or fair complexion
- B. Exposure to sun for great periods of time
- C. Certain diet and foods
- D. History of bad sunburns
Correct Answer: C
Rationale: Diet and foods are not established risk factors for skin cancer, unlike fair complexion, sun exposure, and history of sunburns.