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When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:
- A. The goal of reducing john's fever has been met with full satisfaction of the outcome criteria
- B. The desired goal has been partially met
- C. The goal is not completely met
- D. The goal has been met but not with the desired outcome criteria
Correct Answer: A
Rationale: Paracetamol dropping fever from 40°C to 36.7°C in 10 minutes fully meets the goal of fever reduction e.g., normal range (36.6-38°C) achieved. Partial or unmet goals imply residual fever; undesired criteria suggest side effects (none here). Nurses document this success, per outcome evaluation standards.
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A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- A. Orange juice
- B. Water only
- C. Milk
- D. Apple juice
Correct Answer: A
Rationale: Orange juice enhances iron absorption in iron-deficiency anemia via vitamin C, reducing ferric to ferrous form for better uptake a proven dietary aid. Milk inhibits it, water or apple juice lack this boost. Nurses teach this pairing, improving hemoglobin levels, optimizing therapy for fatigue and pallor relief.
Which of the following statement best describe secondary care?
- A. Routine health check up
- B. Specialized care by referral
- C. Care after diagnosis
- D. Basic health education
Correct Answer: B
Rationale: Secondary care is specialized care by referral (B), per system e.g., cardiologist post-GP. Check-ups (A) and education (D) are primary, post-diagnosis (C) tertiary. B best defines secondary's role, making it correct.
Mr. Gary relied on the nurse for honest care. This is an example of?
- A. Trust
- B. Sympathy
- C. Health literacy
- D. Care coordination
Correct Answer: A
Rationale: Relying on honest care is trust (A) confidence in bond, per definition. Sympathy (B) pity, literacy (C) understanding, coordination (D) organization not trust-specific. A fits Mr. Gary's faith in the nurse, making it correct.
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
- A. chest pain related to cough secondary to pneumonia
- B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
- C. risk for altered family processes secondary to hospitalization
- D. self-esteem deficit situational
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.
How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
- A. Draw up the NPH insulin, then the regular insulin, in the same syringe
- B. Draw up the regular insulin, then the NPH insulin, in the same syringe
- C. Use two separate syringes
- D. Check with the physician
Correct Answer: B
Rationale: Regular (clear) is drawn first, then NPH (cloudy), to avoid contamination.