Nokea
Which of the ff is the diagnostic sign for pericarditis?
- A. Precordial pain
- B. Pericardial friction rub
- C. Hypotension
- D. Rapid and labored respirations INFLAMMATORY
Correct Answer: B
Rationale: The correct answer is B: Pericardial friction rub. This is a key diagnostic sign of pericarditis due to the inflammation of the pericardial layers causing a rough, grating sound heard upon auscultation. Precordial pain (A) is a common symptom but not a specific diagnostic sign. Hypotension (C) and rapid/labored respirations (D) are not typically associated with pericarditis. Therefore, the presence of a pericardial friction rub is crucial in confirming the diagnosis of pericarditis.
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Which of the following groups of terms best describes a nurse-initiated intervention?
- A. Dependent, physician-ordered, recovery
- B. Autonomous, clinical judgment, client outcomes
- C. Medical diagnosis, medication administration
- D. Other health care providers, skill acquisition
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
Mrs. Tan is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which of the following is the priority goal for her immediately after the procedure?
- A. prevent fluid volume deficit
- B. maintain blood pressure control
- C. decrease myocardial contractility
- D. minimize dyspnea
Correct Answer: B
Rationale: The correct answer is B: maintain blood pressure control. After PTCA, the priority goal is to ensure stable hemodynamics. Maintaining blood pressure control is crucial to prevent complications such as bleeding or thrombosis. Choices A, C, and D are incorrect because preventing fluid volume deficit, decreasing myocardial contractility, and minimizing dyspnea are not immediate priorities post-PTCA. Oxygenation and hemodynamic stability take precedence over these concerns.
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
- A. slap the chest wall gently
- B. use vibration techniques to move secretions from affected lung areas during the inspiration phase
- C. perform CPT at least two hours after meals
- D. plan apical drainage at the beginning of the CPT session
Correct Answer: C
Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.
To reduce symptoms of early morning stiffness in a ptient who has rheumatoid arthritis, the nurse can encourage the patient to:
- A. take a hot tub bath or shower in the morning
- B. put joints through passive ROM before tryoing to move them actively
- C. sleep with a hot pad
- D. take two aspirins before arising, and wait 15 minutes before attempting locomotion
Correct Answer: A
Rationale: The correct answer is A: take a hot tub bath or shower in the morning. This is effective as the warm water helps to relax muscles and joints, reducing stiffness. It also improves circulation, which can alleviate morning stiffness in patients with rheumatoid arthritis.
Incorrect choices:
B: Putting joints through passive ROM before active movement may exacerbate stiffness if not done properly.
C: Sleeping with a hot pad may provide temporary relief but does not address the root cause of morning stiffness.
D: Taking aspirin can help with pain but does not directly address stiffness. Waiting 15 minutes before moving may not be as effective as soaking in warm water.
Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
- A. “Data interpretation occurs before data validation.”
- B. “Validation involves looking for patterns in professional standards.”
- C. “Validation involves comparing data with other sources for accuracy.”
- D. “Data interpretation involves discovering patterns in professional standards.”
Correct Answer: C
Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This step ensures that the data is reliable and error-free. Option A is incorrect as data validation typically comes after data collection and cleaning, which precede data interpretation. Option B is incorrect as validation does not specifically focus on professional standards but rather on accuracy and consistency. Option D is incorrect as data interpretation involves analyzing and deriving insights from the validated data, not looking for patterns in professional standards.