Nokea
Which action by the nurse is appropriate?
- A. Observe the patient for abnormal bleeding.
- B. Notify the physician and expect an order to increase the warfarin dose.
- C. Advise the patient to double today’s dose of warfarin.
- D. Administer Vit. K per protocol.
Correct Answer: A
Rationale: The correct answer is A because observing the patient for abnormal bleeding is an appropriate action to monitor for potential complications of warfarin therapy. This aligns with the nursing role in assessing and monitoring patient responses to treatment.
B is incorrect as increasing warfarin dose without physician order can lead to adverse effects. C is incorrect as altering the dose without medical advice can be dangerous. D is incorrect as administering Vitamin K would counteract the effects of warfarin, which is used to prevent blood clotting.
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60 year-old Mrs. Torres arrived just in time for her doctor’s appointment. She complains of pain and stiffness in her back. She is suspected of having osteoporosis. Nurse Ariane will inform Mrs. Torres that the primary complication of osteoporosis is:
- A. Increased trabeculae
- B. poor posture
- C. chronic pain
- D. fractures
Correct Answer: D
Rationale: The correct answer is D: fractures. Osteoporosis weakens bones, making them more prone to fractures. Fractures are the primary complication of osteoporosis due to decreased bone density. Increased trabeculae (A) is incorrect as osteoporosis leads to decreased bone density, not increased. Poor posture (B) may be a result of osteoporosis but is not its primary complication. Chronic pain (C) can occur with osteoporosis but is not as directly linked as fractures.
Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
- A. Assisting with a naloxone challenge test before therapy begins
- B. Discontinuing the drug immediately if signs of dependence appear
- C. Changing the administration route to P.O. if the client can tolerate fluids
- D. Obtaining baseline vital signs before administering the first dose
Correct Answer: D
Rationale: The correct answer is D: Obtaining baseline vital signs before administering the first dose. This intervention is crucial to establish the client's baseline condition before starting morphine therapy. Baseline vital signs provide a comparison for monitoring the client's response to the medication and detecting any adverse effects. This step ensures the nurse can identify and address any potential complications promptly.
Other choices are incorrect:
A: Assisting with a naloxone challenge test before therapy begins - Naloxone challenge test is used to diagnose opioid dependence, not appropriate for monitoring pain management.
B: Discontinuing the drug immediately if signs of dependence appear - Abrupt discontinuation can lead to withdrawal symptoms and should be managed gradually.
C: Changing the administration route to P.O. if the client can tolerate fluids - Changing the route of administration should be based on clinical indications, not solely on the client's ability to tolerate fluids.
Aling Loida, who was admitted for acute pancreatitis, starts complaining of acute abdominal pain, which of the following would be an appropriate nursing interventions by Nurse Norma?
- A. administer morphine sulfate as ordered
- B. obtain daily weights
- C. maintain Aling Loida on high calorie, high protein diet
- D. place her on supine position
Correct Answer: A
Rationale: The correct answer is A: administer morphine sulfate as ordered. This is the appropriate nursing intervention because acute abdominal pain is a common symptom of acute pancreatitis, and morphine sulfate is a commonly used medication to relieve severe abdominal pain. Administering morphine sulfate will help alleviate Aling Loida's discomfort and improve her overall well-being.
Choice B is incorrect because obtaining daily weights is not directly related to managing acute abdominal pain in this scenario. Choice C is incorrect as maintaining Aling Loida on a high calorie, high protein diet may exacerbate her symptoms due to the acute pancreatitis. Choice D is incorrect as placing her on a supine position may not address the underlying cause of the abdominal pain and could potentially worsen her condition.
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: D
Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.
A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?
- A. Discomfort while changing position
- B. Reports pain as a 7 on a 0 to 10 scale
- C. Disruption of tissue integrity
- D. Dull headache
Correct Answer: C
Rationale: The correct answer is C: Disruption of tissue integrity. Acute pain is typically caused by tissue damage or injury, such as a cut or a burn. The nurse would use this assessment data as an etiology for acute pain because it directly relates to the source of the pain. Discomfort while changing position (A) is a symptom of pain but does not provide the underlying cause. Reports pain as a 7 on a 0 to 10 scale (B) is a pain intensity rating and does not explain the cause of the pain. Dull headache (D) is a specific type of pain but is not relevant to the given scenario of tissue disruption.