Nokea
What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.
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Bob is diagnosed with idiopathic thrombocytopenic purpura (ITP). You realize that he has an increased risk of bleeding and you must monitor
- A. WBC and bleeding time.
- B. Prothrombin time (PT) and partial thromboplastin time (PTT).
- C. Platelet count and RBC.
- D. Iron and ferritin levels.
Correct Answer: C
Rationale: Low platelet count increases the risk of bleeding in ITP.
The medical-surgical nurse performs a dressing change on a patient with a history of non-insulin-dependent diabetes. The patient questions why the wound is not healing. Recognizing a teaching opportunity, what response does the nurse offer the patient?
- A. Are you eating enough carbohydrates in your diet?
- B. Have you limited your exercise because of the wound?
- C. How much sleep are you getting at night?
- D. How often do you check your blood sugar levels at home?
Correct Answer: D
Rationale: Blood sugar control significantly impacts wound healing in diabetic patients.
Identify the specific component of acquiring cultural competence reflected in creating a safe environment in which collection of relevant cultural data can be obtained during the health history and physical examination.
- A. Cultural skill
- B. Cultural encounter
- C. Cultural awareness
- D. Cultural knowledge
Correct Answer: A
Rationale: Creating a safe environment involves using cultural skills to gather accurate and meaningful cultural data during assessments.
Priority Decision: The nurse prepares to interview a patient for a nursing history but finds the patient in obvious pain. Which action by the nurse is the best at this time?
- A. Delay the interview until the patient is free of pain.
- B. Administer pain medication before initiating the interview.
- C. Gather as much information as quickly as possible by using closed questions that require brief answers.
- D. Ask only those questions pertinent to the specific problem and complete the interview when the patient is more comfortable.
Correct Answer: A
Rationale: The correct answer is 'Delay the interview until the patient is free of pain.' Pain can interfere with concentration and communication, making it difficult for the patient to provide accurate information. Delaying the interview ensures better quality data collection once the patient is comfortable.
A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Perform range-of-motion exercises
- B. Place suction equipment at the bedside
- C. Encourage the use of an incentive spirometer
- D. Administer an expectorant
Correct Answer: C
Rationale: The correct answer is C: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications by promoting deep breathing and preventing atelectasis. A: Range-of-motion exercises do not directly prevent pulmonary complications. B: Placing suction equipment is important but does not prevent pulmonary complications. D: Administering an expectorant helps with mucus clearance but does not prevent pulmonary complications as effectively as using an incentive spirometer.