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When a nurse is performing a neurological assessment, which of the following is most important to assess first?
- A. Patient's reflexes
- B. Patient's cranial nerve function
- C. Patient's level of consciousness
- D. Patient's pupil response
Correct Answer: C
Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.
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A nurse is assessing a patient with chronic kidney disease. The nurse should prioritize which of the following lab values?
- A. Serum creatinine levels.
- B. Hemoglobin levels.
- C. White blood cell count.
- D. Platelet count.
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine levels. In patients with chronic kidney disease, monitoring serum creatinine levels is crucial because it reflects kidney function. An increase in creatinine levels indicates worsening kidney function. Hemoglobin levels (B) are important in assessing anemia, common in CKD, but not the priority. White blood cell count (C) and platelet count (D) may indicate infection or bleeding, respectively, but are not specific to kidney function in this context.
A patient with diabetes is experiencing a hypoglycemic episode. Which of the following is the nurse's first priority in this situation?
- A. Administering insulin.
- B. Providing a source of fast-acting carbohydrate.
- C. Checking the patient's blood glucose level.
- D. Contacting the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In a hypoglycemic episode, the priority is to raise the blood sugar quickly to prevent further complications. Fast-acting carbohydrates such as glucose tablets or orange juice can rapidly increase blood sugar levels. Administering insulin (choice A) can further lower blood sugar, checking blood glucose levels (choice C) may delay treatment, and contacting the healthcare provider (choice D) is not necessary in the immediate management of hypoglycemia.
What question would you initially ask a patient who has a positive tuberculin test?
- A. Have you recently been hospitalized?
- B. Are you a member of the homeless population?
- C. Have you received bacille Calmette-Guérin (BCG)?
- D. Have you been out of the country over the past 3 months?
Correct Answer: C
Rationale: The correct initial question to ask a patient with a positive tuberculin test is whether they have received bacille Calmette-Guérin (BCG) vaccine. This is because BCG vaccination can cause a false positive result on the tuberculin test due to cross-reactivity with the purified protein derivative (PPD) used in the test. Asking about recent hospitalization (A), homelessness (B), or recent travel out of the country (D) would not provide relevant information regarding the interpretation of the positive tuberculin test.
A nurse is teaching a patient with chronic kidney disease (CKD) about dietary changes. Which of the following statements by the patient indicates proper understanding?
- A. I should limit my intake of foods high in potassium and phosphorus.
- B. I should increase my fluid intake to stay hydrated.
- C. I can eat as much protein as I want to promote healing.
- D. I should drink more sodas for hydration.
Correct Answer: A
Rationale: The correct answer is A. In CKD, limiting potassium and phosphorus intake is crucial to prevent electrolyte imbalances and further kidney damage. Excessive protein intake can worsen kidney function, so the patient should not eat as much protein as they want. Increasing fluid intake is beneficial for hydration, but sodas are not recommended due to their high sugar and phosphorus content, which can be harmful for CKD patients. Therefore, option A is the best choice for proper understanding of dietary changes in CKD.
While auscultating for heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
- A. Document the findings on the patient's record.
- B. Wait 10 minutes, and auscultate the heart again.
- C. Ask another nurse to double-check the finding.
- D. Ask the patient to take deep breaths and check for changes in their physical condition.
Correct Answer: A
Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (B) may not address the immediate need for documentation. Asking another nurse to double-check (C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.