Wednesday, 19 June 2019

Question Of The Day, Neurosensory Disorders
Q. A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to:

A. gather assessment data and notify the physician of the change in the client's status.
B. ask the physician to order an antipsychotic medication for the client.
C. consult with the social worker about the possibility of discharging the client from the facility.
D. tell the client that she'll punish him if he doesn't behave.

Correct Answer: A

Explanation: A client with a head injury who experiences a change in cognition requires further assessment and evaluation, and the nurse should notify the physician of the change in the client's status. The physician should rule out all possible medical causes of the change in mental status before ordering antipsychotic medications or considering discharging the client from the facility. A nurse shouldn't threaten a client with punishment; doing so is a violation of the client's rights.

Tuesday, 18 June 2019

Q. Which finding best indicates that a nursing assistant has an understanding of blood glucose meter use?

A. Verbalizing an understanding of blood glucose meter use
B. Documenting a normal blood glucose level
C. Providing documentation of previous certification
D. Demonstrating correct technique


Correct Answer: D

Explanation: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.


Monday, 17 June 2019

Q. A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:

A. the client requires an antiviral agent.
B. enteric precautions must be continued.
C. enteric precautions can be discontinued.
D. the client's infection may be caused by droplet transmission.

Correct Answer: B

Explanation: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.


Sunday, 16 June 2019

Q. When assessing a client for early septic shock, the nurse should assess the client for which of the following?

A. Cool, clammy skin.
B. Warm, flushed skin.
C. Increased blood pressure.
D. Hemorrhage.




Correct Answer: B

Explanation: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

Saturday, 15 June 2019

Q. Just after delivery, a nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?

A. Rewarm the neonate gradually.
B. Rewarm the neonate rapidly.
C. Observe the neonate hourly.
D. Notify the physician when the neonate's temperature is normal.



Correct Answer: A

Explanation: A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.

Friday, 14 June 2019

Question Of The Day, Postpartum Period
Q. A client is experiencing an early postpartum hemorrhage. Which item in the client's care plan requires revision?

A. Inserting an indwelling urinary catheter
B. Fundal massage
C. Administration of oxytocics
D. Pad count



Correct Answer: D

Explanation: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.


Thursday, 13 June 2019

Question Of The Day, Antepartum Period
Q. A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?

A. 7 weeks' gestation
B. 11 weeks' gestation
C. 17 weeks' gestation
D. 21 weeks' gestation



Correct Answer: B

Explanation: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks' gestation.

Wednesday, 12 June 2019

Q. A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:

A. deeper sleep than CNS depressants.
B. greater sedation than CNS depressants.
C. a calming effect from which the client is easily aroused.
D. more prolonged sedative effects, making the client more difficult to arouse.

Correct Answer: C

Explanation: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.


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