The nurse recorded Mr. Gary's vitals in his chart. This is an example of?

Correct Answer: A

Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.

Correct Answer: D

Rationale: Blood pressure measurement involves listening to arterial sounds via a stethoscope as the cuff deflates. These sounds, known as Korotkoff sounds, occur in five phases, starting with a tapping (systolic pressure) and fading to silence (diastolic pressure). Wheezes are respiratory sounds, murmurs relate to heart valves, and crackles indicate lung fluid none apply to blood pressure. Named after Nikolai Korotkoff, these sounds are a cornerstone of manual blood pressure assessment, ensuring accurate readings essential for diagnosing hypertension or hypotension, reflecting cardiovascular health.

Correct Answer: C

Rationale: Anaphylaxis is a severe IgE-mediated allergic reaction, occurring when prior penicillin exposure sensitizes the immune system, forming antibodies. Re-exposure triggers histamine release, causing symptoms like shock or dyspnea. Atopic sensitization relates to predisposition, not specific drug history. Passive immunity involves transferred antibodies, not self-developed ones. Bivalent antibodies forming during IV use is incorrect sensitization precedes administration. Nurses must assess allergy history, preparing for emergencies like epinephrine administration to reverse this life-threatening response.

Correct Answer: B

Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.

Correct Answer: D

Rationale: The adrenocortical response, triggered by fasting (NPO status), activates stress hormones like cortisol and aldosterone, conserving resources during deprivation. Decreased urine output results from aldosterone's promotion of sodium and water reabsorption in the kidneys, maintaining fluid volume and blood pressure. This adaptation counters the stress of fasting, ensuring homeostasis. Low blood pressure would oppose this, as the response aims to stabilize circulation, not reduce it. Warm, dry skin isn't typical; stress might cause cool, clammy skin from vasoconstriction, but fasting alone doesn't dictate this. Decreased serum sodium levels contradict aldosterone's sodium-retaining effect, which elevates or stabilizes sodium. Decreased urine output aligns with the body's conservation mechanism, making it the expected physiological response in this scenario, critical for nurses to recognize during patient monitoring.