After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be:

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Question 1 of 9

After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be:

Correct Answer: A

Rationale: The correct answer is A: objective. Objective data refers to measurable and observable information obtained through physical examination or diagnostic tests. In this case, the nurse's documentation of the patient's respirations and pulse rate are objective data as they can be quantified and verified by any healthcare professional. This data is not influenced by personal feelings or interpretations, making it objective. Choice B, reflective, is incorrect as it does not describe the nature of the data provided. Choice C, subjective, is also incorrect because subjective data is based on the patient's feelings or perceptions, which is not the case here. Choice D, introspective, is incorrect as it refers to internal self-reflection, not the nature of the data being documented.

Question 2 of 9

The nurse is preparing to examine an infant. Which of the following actions is the most appropriate to perform first?

Correct Answer: C

Rationale: The correct answer is C: Begin with the head. This is the most appropriate action as starting with the head allows the nurse to establish rapport with the infant and assess their level of alertness before progressing further. By starting at the head, the nurse can also observe the infant's facial expressions and interactions with the caregiver, providing valuable information about the infant's overall well-being. Assessing reflexes first (Choice A) may startle the infant, asking the parent to undress the child (Choice B) can be done after the initial assessment, and beginning with the legs (Choice D) does not prioritize the critical areas of observation such as the head and face.

Question 3 of 9

What is the nurse's first priority when a client is receiving a blood transfusion and starts to have chills?

Correct Answer: C

Rationale: The correct answer is C: Monitor for transfusion reactions. When a client receiving a blood transfusion develops chills, it may indicate a transfusion reaction, such as a febrile non-hemolytic reaction. The nurse's first priority is to monitor the client closely for other signs of a reaction, such as fever, rash, or shortness of breath. Stopping the transfusion may be necessary, but monitoring for reactions is crucial to identify and manage any adverse effects promptly. Vital signs should be monitored as part of assessing for reactions. Performing a lumbar puncture is not indicated in this situation and is unrelated to managing a transfusion reaction.

Question 4 of 9

What should the nurse prioritize for a client who is at risk for developing a blood clot after surgery?

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. This is crucial for preventing blood clots post-surgery as they help thin the blood and reduce clot formation. Monitoring for arrhythmias (B) is important but not the priority in this case. While encouraging deep breathing (C) and fluid intake (D) are beneficial for post-surgical recovery, they do not directly address the risk of blood clot formation. Administering anticoagulants is the most effective intervention to prevent blood clots in high-risk surgical patients.

Question 5 of 9

What is the most effective way to manage a client with deep vein thrombosis (DVT)?

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are the primary treatment for DVT as they prevent blood clots from getting bigger and reduce the risk of new clots forming. This helps prevent complications like pulmonary embolism. Elevating the leg and applying compression (option B) can help with symptoms but do not address the underlying cause. Providing anticoagulant therapy (option C) is similar to the correct answer but lacks specificity. Applying compression stockings (option D) can help prevent complications but do not treat the existing clot.

Question 6 of 9

What is the first step in managing a client with an asthma attack?

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. The first step in managing an asthma attack is to address the underlying cause, which is airway constriction. Bronchodilators help relax the muscles around the airways, making it easier for the client to breathe. Providing oxygen therapy (B) can be helpful but addressing airway constriction is the priority. Administering analgesics (C) or pain medication (D) is not appropriate as asthma attacks are not typically associated with pain.

Question 7 of 9

A nurse is teaching a patient with diabetes about the signs and symptoms of hypoglycemia. Which of the following symptoms should the patient be instructed to monitor for?

Correct Answer: B

Rationale: The correct answer is B: Shakiness and dizziness. Hypoglycemia is characterized by low blood sugar levels, leading to symptoms such as shakiness and dizziness. This is because the brain requires glucose for energy, and when levels drop too low, these symptoms can occur. Increased thirst and urination (A) are more indicative of hyperglycemia, where blood sugar levels are too high. Blurred vision and headaches (C) can be symptoms of both hyperglycemia and hypoglycemia but are less specific to hypoglycemia. Fatigue and weight loss (D) are not typical symptoms of hypoglycemia.

Question 8 of 9

A nurse is caring for a 75-year-old patient with diabetes. What is the most important nursing action when assessing this patient?

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's level of understanding about diabetes management. This is the most important nursing action because it enables the nurse to tailor education and interventions to the patient's specific needs. By assessing the patient's understanding, the nurse can address any misconceptions, provide appropriate education, and promote self-management. Checking blood sugar levels every hour (B) is excessive and not necessary unless indicated. Instructing the patient to avoid all sugar-containing foods (C) is overly restrictive and not evidence-based. Ensuring the patient is compliant with their insulin regimen (D) is important but assessing understanding is crucial for effective diabetes management.

Question 9 of 9

Which of the following individuals would the nurse consider at highest risk for a suicide attempt?

Correct Answer: D

Rationale: The correct answer is D because the older adult's statement about joining his wife in heaven and plan to shoot himself indicates clear intent and imminent risk. This individual has a specific plan and timeframe, making them highest risk. Choice A is incorrect because joking about death does not necessarily indicate an imminent risk of suicide. Choice B is incorrect as past suicide attempts are a risk factor, but immediate intent is more concerning. Choice C is incorrect as the adolescent's statement is concerning, but there is no specific plan or timeframe mentioned, lowering the immediate risk compared to choice D.

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