Which of the following are key parameters that produce blood pressure? (Select ONE that does not apply)
- A. Heart rate
- B. Stroke volume
- C. Peripheral resistance
- D. Neuroendocrine hormones
Correct Answer: D
Rationale: Heart rate, stroke volume, and peripheral resistance are indeed key parameters that directly influence blood pressure. Heart rate refers to the number of times the heart beats per minute, affecting how much blood is pumped. Stroke volume is the amount of blood pumped by the heart in one contraction. Peripheral resistance is the resistance of the arteries to blood flow, impacting the pressure needed to push blood through. Neuroendocrine hormones, while they can indirectly influence blood pressure regulation by affecting factors like blood volume and vascular tone, are not direct final parameters that produce blood pressure.
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The nurse is caring for a client with chronic liver disease. Which lab value is most concerning?
- A. Elevated AST and ALT
- B. Decreased albumin level
- C. Elevated bilirubin level
- D. Prolonged PT/INR
Correct Answer: D
Rationale: The correct answer is D, prolonged PT/INR. In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This indicates impaired liver function, leading to a higher risk of bleeding. Elevated AST and ALT (choice A) are indicators of liver damage but do not directly assess the risk of bleeding. Decreased albumin level (choice B) reflects impaired liver function but is not as directly related to bleeding risk as a prolonged PT/INR. Elevated bilirubin level (choice C) is a sign of liver dysfunction, specifically related to bile metabolism, and while important, it is not as directly associated with bleeding risk as a prolonged PT/INR in the context of chronic liver disease.
A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?
- A. Place tape from the cheek to the forehead
- B. Secure tape from the nose to the ear
- C. Attach tape from the lower eyelid to the upper forehead
- D. Use circular bandaging around the head
Correct Answer: C
Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.
While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?
- A. Determine if the drainage has an unpleasant odor.
- B. Monitor the client's white blood cell count (WBC).
- C. Request a culture and sensitivity of the wound.
- D. Cleanse the wound with a sterile saline solution.
Correct Answer: C
Rationale: Requesting a culture and sensitivity of the wound is the most crucial action in this scenario. This will help identify the specific organism causing the infection and determine its sensitivity to antibiotics, guiding appropriate antibiotic therapy. Option A is less critical as odor alone may not provide enough information about the type of infection. Monitoring the client's white blood cell count (WBC) in option B is important but not as immediate as obtaining a wound culture. Cleansing the wound with a sterile saline solution in option D is necessary but should follow after obtaining the culture results to ensure proper treatment.
What is the function of the cervix in reproduction?
- A. Accepts and interprets signals of sexual stimuli
- B. Secretes mucus to facilitate sperm transport
- C. Serves as the site for union of ovum and sperm
- D. Receives the penis during intercourse
Correct Answer: B
Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.
A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?
- A. Administer an epinephrine injection
- B. Call for immediate medical help
- C. Monitor airway, breathing, and circulation
- D. All of the above
Correct Answer: A
Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.
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