Nokea
What are the early signs of increased intracranial pressure (IICP)?
- A. Restlessness, irritability, and confusion
- B. Sudden onset of seizures
- C. Decreased heart rate and pupillary response
- D. Loss of consciousness
Correct Answer: A
Rationale: The correct answer is A: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These signs indicate that the brain is starting to experience pressure, often due to conditions such as trauma, tumors, or hemorrhage. Sudden onset of seizures (choice B) is not typically an early sign of IICP but can occur later as the pressure increases. Decreased heart rate and pupillary response (choice C) are more indicative of late-stage IICP as the brainstem becomes compromised. Loss of consciousness (choice D) is a late sign of IICP when the pressure has significantly increased and is causing significant brain dysfunction.
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A nurse misreads a glucose level and administers insulin for a blood glucose of 210 mg/dL instead of 120 mg/dL. What is the priority intervention?
- A. Monitor for hypoglycemia
- B. Monitor for hyperkalemia
- C. Administer glucose IV
- D. Document the incident
Correct Answer: A
Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on a misread glucose level, which could lead to hypoglycemia due to excessive insulin action lowering blood glucose levels. Monitoring for hypoglycemia allows for prompt recognition and intervention if blood glucose levels drop significantly. Choice B, monitoring for hyperkalemia, is incorrect as administering insulin would not cause hyperkalemia. Choice C, administering glucose IV, is not appropriate at this time since the patient's blood glucose level is already elevated. Choice D, documenting the incident, is important but not the priority at this moment when patient safety is at risk due to potential hypoglycemia.
What is the first medication to give for wheezing due to an allergic reaction?
- A. Albuterol via nebulizer
- B. Cromolyn 20 mg via nebulizer
- C. Methylprednisolone 100 mg IV
- D. Aminophylline 500 mg IV
Correct Answer: A
Rationale: Albuterol is the first-line medication for treating wheezing due to an allergic reaction. Albuterol is a short-acting beta-agonist that helps relieve bronchospasm quickly. Cromolyn is more commonly used for the prevention of asthma symptoms rather than for acute treatment. Methylprednisolone and aminophylline are not the first-line medications for acute wheezing due to an allergic reaction.
A patient with a chest tube has continuous bubbling in the water seal chamber. What does this indicate?
- A. An air leak
- B. A blocked chest tube
- C. Drainage from the site
- D. Blood clot in the chest tube
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This situation requires immediate attention to prevent complications such as lung collapse. A blocked chest tube would typically result in absent or fluctuating bubbling. Drainage from the site would be observed in the collection chamber, not the water seal chamber. A blood clot in the chest tube would lead to cessation of drainage.
A client has a Transient Ischemic Attack (TIA). What should the nurse teach?
- A. Avoid eating within 3 hours of bedtime
- B. Consume liquids between meals
- C. Eat large meals to increase caloric intake
- D. Avoid liquids to prevent aspiration
Correct Answer: A
Rationale: The correct answer is A: Avoid eating within 3 hours of bedtime. For a client with a Transient Ischemic Attack (TIA), it is crucial to avoid eating within 3 hours of bedtime to reduce reflux that can worsen symptoms. Choice B is incorrect because consuming liquids between meals is not specifically related to managing TIA. Choice C is incorrect as eating large meals may not be recommended, especially if the client needs to watch their caloric intake. Choice D is incorrect because avoiding liquids entirely can lead to dehydration and is not a standard recommendation for TIA management.
What are the early signs of hypokalemia on an ECG?
- A. Flattened T waves
- B. Elevated ST segments
- C. Prominent U waves
- D. Widened QRS complex
Correct Answer: A
Rationale: Flattened T waves are an early sign of hypokalemia on an ECG. In hypokalemia, the T waves may flatten and eventually invert. Elevated ST segments are not typically associated with hypokalemia. Prominent U waves are seen in conditions like hypokalemia, but they are not considered an early sign. A widened QRS complex is more commonly associated with hyperkalemia rather than hypokalemia.