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Which of the following substances need to be assessed when completing a family health assessment?
- A. coffee, tea, cola, and cocoa
- B. alcohol, tobacco, and illegal substances
- C. medicines prescribed by a physician
- D. all of the above
Correct Answer: D
Rationale: When assessing drug, alcohol, and tobacco practices among family members, a thorough investigation of prescribed, over-the-counter, and illegal substance-use practices should be made.
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What action should the nurse take?
- A. Reassure patient that pain is normal following surgery.
- B. Administer pm Nifedipine and assess client's response.
- C. Administer pm Meperidine HCL and assess client's response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct Answer: C
Rationale: A sinus tachycardia is a physiological response to pain. Treating the cause of the increased pulse rate requires pain medication.
A 50 milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
- A. 100 ml per hour for one hour.
- B. 60 ml per hour for one-half hour.
- C. 120 ml per hour for one hour.
- D. 50 ml per hour for one hour.
Correct Answer: A
Rationale: One hundred ml in one hour equals 50 ml in 30 minutes, which is what the physician prescribed. Choice 2 is 10 ml more than the physician prescribed for 30 minutes. Choice 3 is the same as Choice 2; it is 10 ml more than the physician prescribed for 30 minutes. Choice 4 only provides 25 ml over 30 minutes, or half the volume prescribed.
After 12 months of cessation of menses, which of the following assessment findings in a client who is taking hormone replacement therapy should the nurse report to the physician immediately?
- A. breast tenderness
- B. weight gain
- C. fluid retention
- D. uterine bleeding
Correct Answer: D
Rationale: Uterine bleeding on combination hormone replacement therapy, after 12 months of menses cessation, indicates an increased risk of carcinoma and should be reported to the physician immediately. Breast tenderness, weight gain, and fluid retention are all routine side effects of hormone replacement therapy. They should be noted in the record and reported to the physician, but they are not urgent.
Which of the following is one of the main goals for Healthy People 2010?
- A. reduction of health care costs
- B. elimination of health disparities
- C. investigation of substance abuse
- D. determination of an acceptable morbidity rate
Correct Answer: B
Rationale: Healthy People 2010 has as its main goal elimination of health disparities among the U.S. population. Healthy People 2010 is a set of health objectives for the nation to achieve over the first decade of the twenty-first century and was developed by the Surgeon General's office. Earlier editions of this report, Healthy People and Healthy People 2000: National Health Promotion and Disease Prevention Objectives established national health objectives and served as the basis for the development of state and community plans.
A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first?
- A. Check the patient's chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screen on the patient.
- D. Request the physician on-call assess the patient.
Correct Answer: B
Rationale: Dizziness can be a sign of hypotension, that may a contraindication with Morphine.