Nokea
Which of the following comments should be given first consideration?
- A. There was a lot of blood and we used three bandages
- B. He pulled the stick out, just now, because it was hurting him
- C. The stick was really dirty and covered with mud
- D. He's a diabetic, so he needs attention right away
Correct Answer: B
Rationale: Pulling out the stick could have caused internal injury, making this the most urgent concern.
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End-of-life palliative nursing care involves
- A. Constant assessment for changes in physiologic functioning.
- B. Administering large doses of analgesics to keep the patient sedated.
- C. Providing as little physical care as possible to prevent disturbing the patient.
- D. Encouraging the patient and family members to verbalize their feelings of sadness
Correct Answer: D
Rationale: Emotional and psychological support for both the patient and family is crucial in palliative care, helping them process feelings and find closure.
What are life-threatening complications of shock?
- A. Catheter infection
- B. Pulmonary edema
- C. Kidney failure
- D. Stasis ulcers
Correct Answer: C
Rationale: Kidney failure is a severe complication of shock due to prolonged hypoperfusion and ischemi
When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find
- A. flaccidity of the upper extremities.
- B. hyperreflexia and spasticity of the upper extremities.
- C. independent use of upper extremities and efficient cough.
- D. impaired diaphragmatic function requiring ventilator support.
Correct Answer: C
Rationale: Patients paralyzed below T4 typically retain independent use of upper extremities.
Why may it pose a challenge to supplement or restrict dietary consumption when providing health-related education to clients from culturally diverse populations?
- A. Cultural beliefs about food may conflict with dietary recommendations.
- B. Clients may prefer traditional healers over modern medicine.
- C. Language barriers may hinder understanding.
- D. All of the above.
Correct Answer: A
Rationale: Cultural beliefs significantly influence dietary habits, requiring sensitivity and adaptation in health education.
What should the nurse do if Wendy develops moderate hypotension and irregular pulse while receiving aminophylline?
- A. Check apical pulse and blood pressure every 10 minutes and continue present aminophylline administration
- B. Discontinue the aminophylline drip and call the physician
- C. Rapidly administer epinephrine 1:1000 intravenously
- D. Slow the rate of aminophylline administration, monitor vital signs, and notify physician
Correct Answer: D
Rationale: Adjusting the infusion rate prevents further adverse effects.