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1. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
- A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
- B. Obtain a thorough history and physical assessment from the patient’s family member.
- C. Immediately perform a complete history and physical assessment to obtain baseline information.
- D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
Correct answer: Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.
2. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Change the IV solution bag.
Correct answer: Check for kinks in the tubing and raise the IV pole.
Rationale: When a nurse assesses a slowed IV rate by gravity with a healthy venous access site in a 2-year-old admitted for dehydration, the next step would be to check for kinks in the tubing and raise the IV pole. This action ensures that the IV fluid can flow freely and reach the patient at the correct rate. Applying a warm compress proximal to the site (Choice A) is not indicated in this situation as it does not address the underlying issue of a slowed IV rate due to mechanical factors. Adjusting the tape that stabilizes the needle (Choice C) or changing the IV solution bag (Choice D) are not the priority actions in this case. These choices do not address the issue of a slowed IV rate caused by kinks in the tubing or the height of the IV pole, which are more likely reasons for the problem observed.
3. A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?
- A. Administer anti-anxiety medications as prescribed by the healthcare provider
- B. Engage in a conversation with the client regarding methods to enhance rest and sleep
- C. Escort the client to a private room and stay with them
- D. Review the client's medical history to determine previous treatment for these issues
Correct answer: Escort the client to a private room and stay with them
Rationale: The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.
4. What is a common error when taking a pulse?
- A. Placing the index finger on the radial artery located on the thumb side of a patient's wrist.
- B. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure.
- C. Counting the pulse for 15 seconds and multiplying the number by four.
- D. None of the above will cause errors.
Correct answer: C: Counting the pulse for 15 seconds and multiplying the number by four
Rationale: The correct answer is counting the pulse for 15 seconds and multiplying the number by four. To accurately assess a patient's heart rate or pulse, it is crucial to count the pulse for a full minute. Counting for only 15 seconds and then multiplying by four may result in an inaccurate heart rate calculation. This approach could miss arrhythmias or intermittent pulsations that could be vital indicators of the patient's condition. Placing the index finger on the radial artery, which is located on the thumb side of the patient's wrist, is the correct technique for taking a pulse. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure is a valid observation and not an error in itself. Therefore, the most common error in this scenario is incorrectly calculating the pulse rate by multiplying a 15-second count by four.
5. Which of the following organs would be described as being located retroperitoneally?
- A. Kidneys
- B. Thymus
- C. Small Intestines
- D. Spleen
Correct answer: Kidneys
Rationale: The term 'retroperitoneal' refers to organs positioned behind the peritoneum. The kidneys are retroperitoneal organs, located outside the peritoneal cavity, against the posterior abdominal wall. This positioning provides them with additional protection from external forces due to the surrounding structures. The thymus, small intestines, and spleen are not retroperitoneal organs. The thymus is located in the mediastinum, the small intestines are intraperitoneal, and the spleen is intraperitoneal and located in the left upper quadrant of the abdomen.
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