Nokea
Which of the following nursing intervention is appropriate when an IV infusion infiltrates?
- A. Elevate the site
- B. Discontinue the infusion
- C. Attempt to flush the tube
- D. Apply warm, moist compress
Correct Answer: B
Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.
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Which of the following is more life threatening?
- A. BP=180/100
- B. BP=160/120
- C. BP=90/60
- D. BP=80/50
Correct Answer: D
Rationale: BP 80/50 is most life-threatening e.g., hypoperfusion risks failure vs. 180/100 (hypertension), 160/120 (severe), 90/60 (borderline). Nurses prioritize this e.g., fluids for stability, per hemodynamics.
Which of the following is true about the NURSING CARE PLAN?
- A. It is nursing centered
- B. Rationales are supported by interventions
- C. Verbal
- D. Atleast 2 goals are needed for every nursing diagnosis
Correct Answer: A
Rationale: The nursing care plan is nursing-centered (A), focusing on nurse-led actions, per planning standards. Rationales support interventions (B) reverses logic, verbal (C) isn't typical, two goals (D) isn't required. A aligns with purpose, making it correct.
Which one of the following four clients is most likely to tolerate pain best?
- A. a client with rheumatoid arthritis
- B. a client who has terminal cancer in stage 1 of grief
- C. an athlete having a knee surgery to prolong his career
- D. a client who has a migraine headache
Correct Answer: C
Rationale: An athlete undergoing knee surgery likely tolerates pain best, motivated by career goals, unlike chronic arthritis, cancer grief, or migraines. Nurses consider this in pain management.
The nurse recorded Mr. Gary's vitals in his chart. This is an example of?
- A. Documentation
- B. Standard precautions
- C. Health policy
- D. Patient education
Correct Answer: A
Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
- A. chest pain related to cough secondary to pneumonia
- B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
- C. risk for altered family processes secondary to hospitalization
- D. self-esteem deficit situational
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.