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Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
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The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B
- C. Metoclopramide
- D. Vitamin K
Correct Answer: B
Rationale: The correct answer is B: Vitamin B. The nurse should instruct the client about Vitamin B because it plays a crucial role in various bodily functions such as energy production, nerve function, and red blood cell formation. Deficiency in Vitamin B can lead to various health issues. Ranitidine, Metoclopramide, and Vitamin K are specific medications that are not typically instructed by nurses unless prescribed by a healthcare provider for specific conditions. Vitamin K is essential for blood clotting, but its education is usually provided by healthcare providers for specific cases.
Which finding should the nurse identify as a potential indication of increased intracranial pressure?
- A. Increasingly severe headache
- B. Bradycardia and hypertension
- C. Dilated, non-reactive pupils
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Increasingly severe headache is a common symptom of increased intracranial pressure due to brain tissue compression. Bradycardia and hypertension can occur as a result of increased intracranial pressure affecting the autonomic nervous system. Dilated, non-reactive pupils may indicate brainstem compression. Therefore, all of these findings are potential indications of increased intracranial pressure. Choices A, B, and C all individually point towards different manifestations of increased intracranial pressure, making them incorrect if considered in isolation.
For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at high volume
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices
- D. Assess the client for suicidal ideation
- E. Place the client in a room near the activity room
Correct Answer: B,D
Rationale: [
B: Asking the client about the content of their hallucinations is indicated to gather important information for assessment and treatment planning.
D: Assessing the client for suicidal ideation is crucial to ensure their safety and provide appropriate interventions.
A: Allowing the client to watch TV at high volume is contraindicated as it may exacerbate symptoms or disturb others.
C: Instructing the client on expected hygiene practices may not be a priority compared to assessing hallucinations and suicidal ideation.
E: Placing the client in a room near the activity room is not mentioned in the question and does not address the client's immediate needs.]
The nurse should identify the cardiac rhythm as which of the following?
- A. Ventricular asystole
- B. Second-degree heart block
- C. Sinus Tachycard
- D. Atrial fibrillation
Correct Answer: D
Rationale: The correct answer is D: Atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and rapid heart rate. This can be identified on an ECG by the absence of distinct P waves and irregular R-R intervals. Ventricular asystole (A) is the absence of ventricular contractions, second-degree heart block (B) is characterized by intermittent conduction block between the atria and ventricles, and sinus tachycardia (C) is a regular rapid heart rate originating from the sinus node.
Which pain management technique should the nurse suggest?
- A. Provide information about the use of hydrotherapy during labor
- B. Encourage the use of breathing techniques to manage pain.
- C. Suggest the use of massage or counterpressure to relieve discomfort.
- D. Recommend positioning changes, such as walking or rocking, to ease pain.
- E. Support the use of relaxation techniques, such as visualization, to reduce stress.
Correct Answer: B
Rationale: The correct answer is B: Encourage the use of breathing techniques to manage pain. Breathing techniques help in pain management by promoting relaxation, reducing anxiety, and increasing oxygen flow. This can help the laboring individual cope better with contractions. Other choices are less effective for pain management in labor. A: Hydrotherapy can be beneficial, but breathing techniques are more universally applicable. C: Massage and counterpressure can help, but may not be as effective as breathing techniques during labor. D: Positioning changes are helpful, but breathing techniques are more directly focused on pain management. E: Relaxation techniques like visualization are useful, but breathing techniques are more specifically targeted at managing pain.