Nokea
What does the mnemonic PERLA stand for in the assessment of the eyes?
- A. Pupils equally reactive to light and accommodation
- B. Patient eyes are equally recessed and responsive to light and acuity
- C. Patient eyes are equally responsive to light and acuity
- D. Pupils equally reactive to light and acuity
Correct Answer: A
Rationale: The correct answer is A: 'Pupils equally reactive to light and accommodation.' PERLA is a mnemonic used in eye assessments to check for Pupils being equally reactive to Light and Accommodation. Choice B is incorrect as it includes irrelevant information about the eyes being recessed. Choice C is incorrect as it is missing the mention of pupils and accommodation. Choice D is incorrect as it misses the mention of accommodation.
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A nurse on a med-surg unit is caring for a group of clients with the assistance of an LPN and an AP. Which of the following tasks should the nurse assign to the LPN?
- A. Reinforce dietary teaching with a client who has heart disease.
- B. Obtaining a urine specimen from an older adult client
- C. Providing postmortem care for a client who has just died.
- D. Accompanying a client who just had a wound debridement to PT.
Correct Answer: A
Rationale: The correct answer is to reinforce dietary teaching with a client who has heart disease. This task falls within the LPN's scope of practice as they can provide education and support related to nutrition. Obtaining a urine specimen (Choice B) is typically performed by nursing assistants. Providing postmortem care (Choice C) is a sensitive task usually performed by registered nurses. Accompanying a client to physical therapy (Choice D) is often done by nursing assistants or other supportive staff.
Alcohol, caffeine, or drugs are high-risk factors that all fall under which broad classification of risk factors?
- A. Social demographic
- B. Environmental
- C. Biophysical
- D. Psychosocial
Correct Answer: D
Rationale: The correct answer is D: Psychosocial. Alcohol, caffeine, or drug use are considered psychosocial risk factors as they are related to individual behavior, lifestyle choices, and social interactions. Choices A, B, and C are incorrect. Social demographic factors (choice A) refer to characteristics of a population such as age, gender, education, income, etc. Environmental factors (choice B) include physical surroundings like air quality, housing conditions, etc. Biophysical factors (choice C) involve biological aspects like genetics, physiology, and health conditions.
While administering penicillin intravenously, you notice that the patient becomes hypotensive with a bounding, rapid pulse rate. What is the first action you should take?
- A. Decrease the rate of the intravenous medication flow.
- B. Increase the rate of the intravenous medication flow.
- C. Call the doctor.
- D. Stop the intravenous flow.
Correct Answer: D
Rationale: The correct action to take when a patient becomes hypotensive with a bounding, rapid pulse rate after administering penicillin intravenously is to stop the intravenous flow immediately. This can help prevent further complications by discontinuing the administration of the medication that might be causing the adverse effects. Decreasing or increasing the rate of medication flow may not address the underlying issue of the patient's adverse reaction. While it's important to involve the healthcare provider in such situations, the immediate priority is to halt the administration of the medication.
A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using?
- A. Structure audit
- B. Benchmarking
- C. Risk benefit analysis
- D. Root cause analysis
Correct Answer: B
Rationale: The correct answer is B: Benchmarking. Benchmarking involves comparing performance metrics with those from other units or institutions, which is exactly what the nurse is doing by comparing the rate of medication errors on their medical unit to the rate from a medical unit in a magnet hospital. Choice A, Structure audit, is not relevant to this scenario as it focuses on assessing the physical, organizational, or procedural structures in a healthcare setting. Choice C, Risk benefit analysis, involves weighing the potential risks and benefits of a particular course of action, not comparing performance metrics. Choice D, Root cause analysis, is a method used to identify the underlying causes of problems or adverse events, not to compare performance metrics between units.
A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?
- A. ST depression
- B. Inverted T wave
- C. Prominent U wave
- D. Tall peaked T waves
Correct Answer: D
Rationale: The correct answer is 'Tall peaked T waves.' Tall peaked T waves are characteristic ECG changes associated with hyperkalemia. In hyperkalemia, the elevated potassium levels affect the myocardium, leading to changes in the ECG. ST depression (Choice A) is more commonly associated with myocardial ischemia or infarction. Inverted T wave (Choice B) is seen in conditions like myocardial ischemia or CNS events. Prominent U wave (Choice C) is typically associated with hypokalemia or certain medications. Therefore, in this scenario, the nurse would expect to note tall peaked T waves on the electrocardiogram due to the elevated potassium level.