Nokea
You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:
- A. Take the blood pressure reading on both arms for comparison
- B. Listen to and identify the phases of Korotkoff sounds
- C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
- D. Observe procedures for infection control
Correct Answer: B
Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.
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What is the most effective way to limit the number of microorganisms in the hospital?
- A. Using strict aseptic technique in all procedures
- B. Wearing a mask and gown when caring for all patients with communicable diseases
- C. Sterilizing all instruments
- D. Handwashing
Correct Answer: A
Rationale: The most effective way to limit the number of microorganisms in the hospital is by using strict aseptic technique in all procedures. This approach ensures that the risk of introducing harmful microorganisms into the hospital environment or patients is minimized. Choice B, wearing a mask and gown when caring for patients with communicable diseases, is important but not as comprehensive as using aseptic technique in all procedures. Sterilizing all instruments (Choice C) is crucial for preventing infections but may not address all avenues of microorganism transmission. Handwashing (Choice D) is a fundamental practice in infection control but alone may not be as effective as utilizing aseptic techniques in all procedures to limit microorganisms in the hospital.
An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?
- A. Marijuana
- B. Amphetamines
- C. Barbiturates
- D. Anxiolytics
Correct Answer: A
Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.
In an extreme situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has to be correctly written and signed by the physician within:
- A. 24 hours
- B. 36 hours
- C. 48 hours
- D. 12 hours
Correct Answer: B
Rationale: In an extreme situation where no other resident or intern is available, if a nurse receives telephone orders, the order has to be correctly written and signed by the physician within 36 hours. This time frame ensures timely documentation and validation of the orders. Choice A (24 hours) is too short a period for busy physicians to fulfill the task. Choice C (48 hours) is too long and delays the incorporation of physician orders into the patient's care plan. Choice D (12 hours) may not provide enough time for the physician to review and sign the order, especially in situations where immediate attention is not required.
What are sheets/forms that provide an efficient and time-saving way to record information that must be obtained repeatedly at regular and/or short intervals of time? This does not replace progress notes; instead, it records information on vital signs, intake and output, treatment, postoperative care, postpartum care, and diabetic regimen, etc. These are used whenever specific measurements or observations need to be documented repeatedly. What is this?
- A. Nursing Kardex
- B. Graphic Flow Sheets
- C. Discharge Summary
- D. Medicine and Treatment Record
Correct Answer: A
Rationale: The correct answer is A, Nursing Kardex. Nursing Kardex is a tool used for documenting essential patient information that needs to be recorded repeatedly at regular intervals. It includes vital signs, intake and output, treatment details, postoperative care, postpartum care, and diabetic regimen. This tool is efficient and time-saving for healthcare professionals. Choice B, Graphic Flow Sheets, may be used for visual representation of patient data but is not specifically designed for repeated documentation of essential information. Choice C, Discharge Summary, is a document outlining the patient's care and condition at the time of discharge, not for repeated recording of ongoing data. Choice D, Medicine and Treatment Record, focuses more on specific medications and treatments rather than a comprehensive recording of various patient data needed at regular intervals.
All of the following are seen in a child with measles. Which one is not?
- A. Reddened eyes
- B. Coryza
- C. Pustule
- D. Cough
Correct Answer: C
Rationale: Measles typically presents with symptoms like reddened eyes, coryza (inflammation of the mucous membrane in the nose), and cough. However, pustules are not a common symptom of measles. Pustules are more characteristic of conditions like chickenpox rather than measles. Understanding these distinctions is crucial for accurate diagnosis and appropriate treatment.