Nokea
Which of the following would have the highest priority in septic shock?
- A. Monitoring temperature.
- B. Monitoring pupillary reaction.
- C. Monitoring airway, breathing, circulation (ABC).
- D. Monitoring ANA and RF levels.
Correct Answer: C
Rationale: Maintaining ABCs is critical in septic shock.
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What is the main drawback of the botulism antitoxin that the nurse should be aware of?
- A. It causes 9% hypersensitivity.
- B. It requires monthly booster dosages.
- C. It is not available from the CDC.
- D. It is not available as a pre-exposure vaccine.
Correct Answer: D
Rationale: The correct answer is D because botulism antitoxin is not available as a preventive vaccine.
What are the recommendations that can help develop culturally sensitive nursing care?
- A. Learn about different cultures,avoid stereotypes and involve clients in decision-making.
- B. Focus solely on universal care standards.
- C. Ignore cultural differences.
- D. All of the above.
Correct Answer: A
Rationale: Understanding cultural nuances and involving clients in care decisions enhances cultural competence and improves outcomes.
What are these sensory phenomena called when a client hears voices or sees images that do not objectively exist?
- A. Mania
- B. Delusions
- C. Seasonal affective disorder
- D. Hallucinations
Correct Answer: D
Rationale: Hallucinations involve perceiving things that are not present, such as hearing voices or seeing images.
In monitoring patients who are at risk for spinal cord compression related to tumor growth, what is the most likely early manifestation?
- A. Sudden-onset back pain.
- B. Motor loss.
- C. Constipation.
- D. Urinary hesitancy.
Correct Answer: A
Rationale: Sudden-onset back pain is often the first symptom of spinal cord compression and warrants urgent evaluation.
Which nursing actions are completed by the scrub nurse (select all that apply)?
- A. Prepares instrument table
- B. Documents intraoperative care
- C. Remains in the sterile area of the OR
- D. Checks mechanical and electrical equipment
Correct Answer: A
Rationale: The scrub nurse manages sterile instruments and assists the surgical team within the sterile field.