Nokea
You were about to give AM care, a patient requested for pain medication after returning from surgery 24 hours ago.
What do you do first?
- A. Take VS, assess pain, do AM care.
- B. Give medication, take VS, assess pain, do AM care.
- C. Take VS, give medication, do AM care.
- D. Perform AM care, give medication, assess pain.
Correct Answer: C
Rationale: Vital signs must be assessed before administering pain medication to ensure the patient is stable and to establish a baseline.
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John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.
The level of the water in the water-seal chamber is at
- A. 2 cm
- B. -20 cm
- C. -10 cm
- D. -80 cm
Correct Answer: A
Rationale: The water-seal chamber is maintained at 2 cm to prevent air entry.
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?
- A. Elicit reflexes
- B. Measure height and weight
- C. Auscultate heart and lungs
- D. Examine the ears
Correct Answer: C
Rationale: Auscultate heart and lungs. Performing this during a quiet moment ensures clear sound detection.
An adult is scheduled for a magnetic resonance imaging (MRI) exam today. Which finding must be reported immediately?
- A. The client has pins in her toes.
- B. The client usually wears a necklace.
- C. The client used to work in the x-ray department.
- D. The client has a pacemaker.
Correct Answer: D
Rationale: Pacemakers are contraindicated for MRI due to magnetic field interference, risking device malfunction, requiring immediate reporting, unlike pins, necklaces, or prior x-ray work.
A diet rich in calcium over a lifetime will decrease the risk of
Heart disease
- A. Osteoporosis
- B. Gout
- C. Rheumatoid Arthritis
Correct Answer: B
Rationale: A diet rich in calcium over a lifetime will decrease the risk of osteoporosis by strengthening bones.
B.C underwent skin grafting. Vital signs are BP 124/68; HR 100 bpm; RR 24; T 37.7 °C.
Potential complication that can be possibly developed will be:
- A. Sepsis
- B. Hypovolemic
- C. Pain
- D. Electrolyte imbalance
Correct Answer: A
Rationale: Infection, such as sepsis, is a serious complication of skin grafting due to the risk of microbial invasion at the graft site.