Nokea
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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Which of the following substances need to be assessed when completing a family health assessment?
- A. coffee, tea, cola, and cocoa
- B. alcohol, tobacco, and illegal substances
- C. medicines prescribed by a physician
- D. all of the above
Correct Answer: D
Rationale: When assessing drug, alcohol, and tobacco practices among family members, a thorough investigation of prescribed, over-the-counter, and illegal substance-use practices should be made.
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.
Which of the following developmental milestones for a 6-month-old child should be screened by the nurse during a routine office visit?
- A. standing while holding something
- B. rolling over
- C. sitting up
- D. creeping
Correct Answer: B
Rationale: Rolling over occurs between 4 and 6 months of age. Sitting up occurs between 7 and 8 months, creeping between 9 and 10 months, and standing between 8 and 10 months.
A nurse suspects a patient is developing Bell's Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?
- A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
- B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
- C. Test the sensation of the facial muscles and sensation of the back of the tongue.
- D. Test the sensation of the facial muscles and sensation of the front of the tongue.
Correct Answer: B
Rationale: The facial nerve (VII) is motor to the face and sensory to the anterior tongue.
A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for:
- A. solutions administered in obstetrics.
- B. dilute antibiotics.
- C. large volumes of IV solution.
- D. the neonatal and pediatric populations.
Correct Answer: D
Rationale: Small volumes of medication or fluids are delivered and sometimes at slow rates to neonates and pediatric clients. The syringe pump allows precise infusion of small volumes. Choice 1 is incorrect because a syringe pump can be used in almost any setting, but is not generally for adult clients. Choices 2 and 3 are incorrect because large volumes of fluids are not administered with a syringe pump.