Nokea
What is the priority nursing action for this patient?
- A. Obtain an order for a blood alcohol level
- B. Contact the family to obtain additional history and baseline information
- C. Administer naloxone (Narcan) 2-4 mg as ordered
- D. Administer IV fluid support with supplemental thiamine as ordered
Correct Answer: D
Rationale: Fluid support and thiamine administration address potential dehydration and nutritional deficits in intoxicated patients.
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When performing a physical examination, what approach is most important for the nurse to use?
- A. A head-to-toe approach to avoid missing an important area
- B. The same systematic, efficient sequence for all examinations
- C. A sequence that is least revealing and embarrassing for the patient
- D. An approach that allows time to collect the nursing history data while performing the examination
Correct Answer: B
Rationale: The correct answer is 'The same systematic, efficient sequence for all examinations.' Consistency ensures thoroughness and reduces the likelihood of missing critical details.
Which of the following would be appropriate to delegate to the nursing assistant?
- A. Assist the child to remove outer clothing
- B. Advise the parent to use acetaminophen instead of aspirin
- C. Explain the need for cool fluids
- D. Prepare and administer a tepid bath
Correct Answer: A
Rationale: Removing outer clothing is a simple task that does not require clinical judgment.
What is the most common cause of amblyopia?
- A. Strabismus
- B. Cataracts
- C. Astigmatism
- D. Glaucoma
Correct Answer: A
Rationale: Strabismus, or misalignment of the eyes, is the leading cause of amblyopia in children.
How can a nurse foster effective coping skills?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
What does weight gain during the postoperative period indicate?
- A. Urine retention
- B. Healthy recovery
- C. Paralytic ileus
- D. Hypoxia
Correct Answer: C
Rationale: The correct answer is C because weight gain can indicate fluid retention due to paralytic ileus.