Nokea
Which of the following assessment finding is typical of extracellular fluid loss?
- A. Distended jugular veins
- B. Elevated hematocrit level
- C. Rapid thready pulse
- D. Increased serum sodium level
Correct Answer: C
Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.
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Founder of the PNA
- A. Julita Sotejo
- B. Anastacia Giron Tupas
- C. Eufemia Octaviano
- D. Anesia Dionisio
Correct Answer: B
Rationale: Anastacia Giron-Tupas founded the Philippine Nurses Association in 1922, advancing Filipino nursing's professional status e.g., advocating licensure. Sotejo, Octaviano, and Dionisio contributed differently. Her leadership at PGH and PNA shaped national standards, a key historical milestone in local nursing.
A client is receiving 115 ml/hr of continuous IVF. The nurse noticed that the venipuncture site was red and swollen. Which of the following interventions would the nurse perform first?
- A. Stop the infusion
- B. Call the attending physician
- C. Slow that infusion to 20 ml/hr
- D. Place a cold towel on the site
Correct Answer: A
Rationale: Stopping the infusion is the nurse's first intervention when observing a red, swollen venipuncture site, as this may indicate phlebitis, infiltration, or infection. Halting the IV prevents further tissue damage or fluid extravasation, prioritizing patient safety. Redness and swelling suggest inflammation or leakage into surrounding tissue, requiring immediate cessation to assess severity and plan next steps, like site relocation or physician consultation. Calling the physician follows assessment, not precedes stopping the infusion, as the nurse acts within scope to mitigate harm first. Slowing the infusion might worsen damage if fluid is already escaping the vein. A cold towel could reduce swelling later but doesn't address the active infusion causing the issue. Stopping the infusion is the critical initial step, enabling evaluation and preventing complications, aligning with nursing's focus on prompt, protective action.
The nurse adapted care to Mr. Gary's cultural diet. This is an example of?
- A. Cultural competence
- B. Trust
- C. Health promotion
- D. Nursing informatics
Correct Answer: A
Rationale: Adapting to cultural diet is cultural competence (A) diversity respect, per definition. Trust (B) bond, promotion (C) well-being, informatics (D) tech not culture-specific. A fits the nurse's sensitivity to Mr. Gary's needs, making it correct.
The nurse touched Mr. Gary without consent during care. This is an example of?
- A. Battery
- B. Assault
- C. Justice
- D. Nonmaleficence
Correct Answer: A
Rationale: Touching without consent is battery (A) unconsented contact, per law. Assault (B) threat, justice (C) fairness, nonmaleficence (D) harm avoidance not contact-specific. A fits the nurse's breach of Mr. Gary's autonomy, making it correct.
Mr. Gary uses acupuncture along with his meds. This is an example of?
- A. Complementary therapy
- B. Alternative therapy
- C. Therapeutic touch
- D. Health promotion
Correct Answer: A
Rationale: Acupuncture with meds is complementary therapy (A) with conventional, per definition. Alternative (B) replaces, touch (C) hands, promotion (D) well-being not combo-specific. A fits integrated use, making it correct.