Nokea
What is the first symptom to occur in hypovolemia?
- A. Hypotension
- B. Thirst
- C. Central venous pressure below 2 to 3 mmHg
- D. Urine specific gravity high
Correct Answer: B
Rationale: Thirst is the earliest indicator of hypovolemia, as the body signals the need for fluid replacement before more severe signs like hypotension develop.
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A patient scheduled for hip replacement surgery in the early afternoon is NPO but receives and ingests a breakfast tray with clear liquids on the morning of surgery. What response does the nurse expect when the anesthesia care provider is notified?
- A. Surgery will be done as scheduled.
- B. Surgery will be rescheduled for the following day.
- C. Surgery will be postponed for 8 hours after the fluid intake.
- D. A nasogastric tube will be inserted to remove the fluids from the stomach.
Correct Answer: A
Rationale: Clear liquids are generally acceptable up to 2 hours before surgery, allowing the procedure to proceed as planned.
What is the term that describes a type of therapy or medicine used in conjunction with conventional medicine?
- A. Integrative medicine
- B. Alternative therapy
- C. Allopathic medicine
- D. Complementary therapy
Correct Answer: D
Rationale: Complementary therapy works alongside conventional medicine to enhance overall care.
When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find
- A. flaccidity of the upper extremities.
- B. hyperreflexia and spasticity of the upper extremities.
- C. independent use of upper extremities and efficient cough.
- D. impaired diaphragmatic function requiring ventilator support.
Correct Answer: C
Rationale: Patients paralyzed below T4 typically retain independent use of upper extremities.
To communicate with a patient who does not speak the dominant language, the nurse should
- A. Speak slowly and enunciate clearly in a slightly louder voice.
- B. Use gestures and pantomime words while verbalizing specific words.
- C. Use family members rather than strangers as interpreters to increase the patient’s feeling of comfort.
- D. Use a dictionary or phrase books that translate from both the nurse’s language and the patient’s language.
Correct Answer: A
Rationale: Speaking slowly, using gestures, and utilizing translation tools facilitate effective communication. Using family members as interpreters can introduce bias and inaccuracies.
Which task is appropriate to delegate to the nursing assistant?
- A. Chest compressions
- B. Bag-valve mask ventilation
- C. Assisting with oral intubation
- D. Placing the defibrillator pads
Correct Answer: A
Rationale: Chest compressions are a physical task that can be delegated to a nursing assistant under supervision.