Nokea
What goal assumes the highest priority for Ms. Weeze with an acute asthmatic attack?
- A. Preventing future attacks
- B. Maintaining quiet, restful environment
- C. Observing for signs of drug toxicity
- D. Relieving bronchial spasm
Correct Answer: D
Rationale: Relieving bronchospasm is critical to restore adequate airflow.
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When caring for a client with pain, which of the following is essential throughout the client’s care?
- A. Giving assurance that pain management is a nursing and agency priority.
- B. Giving assurance that pain relief will be immediate and effective.
- C. Giving assurance that pain relief will be permanent.
- D. Giving assurance that pain has a psychological basis and can be easily managed.
Correct Answer: A
Rationale: The correct answer is A because ensuring that pain management is prioritized by both nursing staff and the healthcare facility is crucial for consistent and effective care.
The first priority to care for the patient with a new fracture includes assessing
- A. Respiratory rate and effort, as well as pulse.
- B. The fracture site for bleeding.
- C. For signs of infection at the wound site of an open fracture.
- D. For circulation and sensation distal to the fracture site.
Correct Answer: D
Rationale: Assessing circulation and sensation ensures no compromise to distal structures.
Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?
- A. Hypoxemia
- B. Neurologic injury
- C. Distended bladder
- D. Cardiac dysrhythmias
Correct Answer: A
Rationale: Hypoxemia is a common cause of agitation and delirium during emergence from anesthesia.
While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse?
- A. Immediately.
- B. Several days.
- C. 2 weeks.
- D. 1 month.
Correct Answer: C
Rationale: Lithium typically takes 2 weeks to show therapeutic effects.
Sixty-five-year-old Dominic is being transferred into the postanesthesia care unit (PACU) from the OR. Once there, initial assessment will focus on
- A. Airway, breathing, circulation, and wound site.
- B. Intake, output, and intravenous access.
- C. Abdominal sounds, oxygen level, and level of consciousness.
- D. Pulse oximetry, pupil responses, and deep tendon reflexes.
Correct Answer: A
Rationale: ABCs are prioritized in the immediate postoperative period.