Nokea
Which of the following is TRUE about the blood pressure determinants?
- A. Hypervolemia lowers BP
- B. Hypervolemia increases GFR
- C. HCT of 70% might decrease or increase BP
- D. Epinephrine decreases BP
Correct Answer: C
Rationale: Hematocrit (HCT) 70% e.g., polycythemia can raise BP (viscosity) or lower it (poor flow), unlike hypervolemia (raises BP, GFR), or epinephrine (raises BP). Nurses assess this e.g., in anemia for variable impacts, per circulatory dynamics.
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When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:
- A. The goal of reducing john's fever has been met with full satisfaction of the outcome criteria
- B. The desired goal has been partially met
- C. The goal is not completely met
- D. The goal has been met but not with the desired outcome criteria
Correct Answer: A
Rationale: Paracetamol dropping fever from 40°C to 36.7°C in 10 minutes fully meets the goal of fever reduction e.g., normal range (36.6-38°C) achieved. Partial or unmet goals imply residual fever; undesired criteria suggest side effects (none here). Nurses document this success, per outcome evaluation standards.
When charting in the client's record or chart, the nurse most needs to do which one of the following things?
- A. Date and sign each entry.
- B. Chart every two hours.
- C. Use ballpoint pen and not pencil.
- D. Cross out errors so others can't read them.
Correct Answer: A
Rationale: Dating and signing each chart entry is most essential, establishing a legal timeline and accountability for actions. Fixed intervals aren't mandatory, pens ensure permanence but aren't the priority, and crossing out errors risks misinterpretation. This practice validates care, crucial for nursing documentation integrity.
How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
- A. Draw up the NPH insulin, then the regular insulin, in the same syringe
- B. Draw up the regular insulin, then the NPH insulin, in the same syringe
- C. Use two separate syringes
- D. Check with the physician
Correct Answer: B
Rationale: Regular (clear) is drawn first, then NPH (cloudy), to avoid contamination.
As a nurse manager, which of the following best describes this function?
- A. Initiate modification on client's lifestyle
- B. Protect client's right
- C. Coordinates the activities of other members of the health team in managing patient care
- D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution
Correct Answer: D
Rationale: A nurse manager's role encompasses planning (vision formulation), organizing (team coordination), directing (training), and controlling (audits), per management theories like Venzon's. This holistic function e.g., setting care standards, training staff, evaluating outcomes ensures quality across a unit, unlike narrower roles like lifestyle change (change agent), rights protection (advocate), or team coordination (case manager). It's a strategic position driving institutional excellence, pivotal in healthcare leadership.
The nurse is teaching a client who underwent a hypophysectomy for hypopituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.
- A. Nose blowing
- B. Teeth brushing
- C. Bending forward
- D. Lying in a semi-Fowler's position
Correct Answer: A
Rationale: Post-hypophysectomy, nose blowing (A) risks CSF leak or meningitis by disrupting the surgical site. Brushing (B) and semi-Fowler's (D) are safe. Bending (C) is risky but less immediate. A is correct. Rationale: Nasal pressure can breach the pituitary fossa repair, a critical complication in early recovery, per post-operative neurosurgery care, unlike benign actions.