Nokea
You have just received the morning report from the night shift nurses. List the order of priority for assessing and caring for these patients.
- A. A patient who developed tumor lysis syndrome around 5:00 am.
- B. A patient with frequent reports of break-through pain over the past 24 hours.
- C. A patient scheduled for exploratory laparotomy this morning.
- D. A patient with anticipatory nausea and vomiting for the past 24 hours.
Correct Answer: A
Rationale: Tumor lysis syndrome is a life-threatening condition requiring immediate intervention, making it the top priority.
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On the first postoperative day following a bowel resection, the patient complains of abdominal and incisional pain rated 9 on a scale of 0 to 10. Postoperative orders include morphine, 4 mg IV q2 hr, for pain and may repeat morphine, 4 mg IV, for breakthrough pain. The nurse determines that it has been only 2 hours since the last dose of morphine and wants to wait a little longer. What effect does the nurse’s action have on the patient?
- A. Protects the patient from addiction and toxic effects of the drug
- B. Prevents hastening or causing a patient’s death from respiratory dysfunction
- C. Contributes to unnecessary suffering and physical and psychosocial dysfunction
- D. Indicates that the nurse understands the adage of “start low and go slow” in administering analgesics
Correct Answer: C
Rationale: The correct answer is C. Delaying pain relief contributes to unnecessary suffering and can negatively impact recovery.
The following are the monometer measurements of four clients. Which of them has normal intraocular pressure (IOP)?
- A. 8 mm Hg
- B. 11 mm Hg
- C. 25 mm Hg
- D. 28 mm Hg
Correct Answer: B
Rationale: Normal intraocular pressure ranges from 10 to 21 mm Hg. Therefore, 11 mm Hg is within the normal range.
Why does the nurse advise a client with painless lesions, after exposure to anthrax, to avoid contact with others?
- A. So the client is not exposed to pathogens.
- B. Because the sight of the lesions may cause distress and panic.
- C. Because the lesions may release more spores.
- D. Skin infection is one form of anthrax that spreads by direct contact.
Correct Answer: C
Rationale: The correct answer is C because anthrax lesions can release spores that may infect others.
Which type of stress helps individuals pursue goals and solve problems?
- A. Energy stress
- B. Active stress
- C. Eustress
- D. Distress
Correct Answer: C
Rationale: Eustress is positive stress that motivates individuals to achieve goals, learn new skills, and manage crises effectively.
In which direction does the nurse hold the syringe when irrigating the ear to remove wax?
- A. Toward the roof of the canal
- B. Toward the eardrum
- C. Toward the nasal cavity
- D. Toward the helix
Correct Answer: A
Rationale: Directing the stream toward the roof of the canal helps dislodge wax without damaging the eardrum.