#1
In a clinical setting, which vital sign is considered the most crucial for immediate assessment?
Heart rate
ExplanationHeart rate reflects cardiac function and is vital for immediate assessment of patient's condition.
#2
Which nursing action is essential when caring for a patient with a chest tube drainage system?
Keeping the drainage system below chest level
ExplanationMaintaining the chest tube drainage system below chest level prevents backflow and air leaks, ensuring proper function.
#3
When prioritizing care for a patient with chronic pain, what should the nurse consider as a primary goal?
Reduction of pain to a tolerable level
ExplanationPrimary goal is to alleviate pain to a level tolerable for the patient, enhancing quality of life and function.
#4
When assessing a postoperative patient's surgical wound, what finding would be considered normal?
Serous drainage with a mild odor
ExplanationSerous drainage with mild odor is normal in early wound healing, indicating normal wound exudate.
#5
In a laboring woman, which finding indicates the need for immediate intervention?
Contractions lasting 60 seconds every 2 minutes
ExplanationFrequent contractions lasting 60 seconds every 2 minutes suggest rapid progression of labor, requiring immediate intervention to prevent complications.
#6
A patient with a high fever, altered mental status, and a stiff neck is suspected of having which condition?
Meningitis
ExplanationClassic triad of symptoms indicating potential meningitis, requiring urgent evaluation and treatment.
#7
During a mass casualty event, which patient should be prioritized for immediate care?
An unconscious patient with difficulty breathing
ExplanationImmediate attention to unconsciousness and breathing difficulty, indicative of critical condition.
#8
In a postoperative patient, which sign may indicate potential complications such as hemorrhage or shock?
Increased respiratory rate
ExplanationIncreased respiratory rate may indicate hypoxia or pain, potential signs of complications requiring prompt assessment.
#9
When caring for a patient with diabetes, which assessment finding requires immediate attention?
Decreased blood glucose levels
ExplanationDecreased blood glucose levels indicate hypoglycemia, requiring immediate intervention to prevent complications.
#10
When assessing a patient with suspected sepsis, which vital sign alteration is commonly observed?
Tachypnea
ExplanationTachypnea is a common sign of sepsis, indicating systemic inflammation and respiratory distress.
#11
When caring for a patient with a nasogastric tube, what is the priority nursing action?
Assessing the tube placement before feeding or medication administration
ExplanationAssessing tube placement prevents complications such as aspiration or improper medication delivery.
#12
In a patient with chronic heart failure, which assessment finding indicates fluid retention?
Crackles in the lungs
ExplanationCrackles in the lungs indicate pulmonary edema, a common manifestation of fluid retention in heart failure.
#13
In a pediatric emergency, what is the most critical assessment parameter?
Respiratory rate
ExplanationRespiratory rate is crucial in pediatric emergencies, indicating respiratory distress or failure.
#14
When prioritizing nursing care, what should be the immediate focus for a patient experiencing anaphylaxis?
Administering epinephrine
ExplanationImmediate administration of epinephrine is crucial to counteract anaphylaxis, preventing worsening symptoms.
#15
What is the primary purpose of the Glasgow Coma Scale (GCS) in assessing a patient's neurological status?
Quantifying level of consciousness
ExplanationGCS quantifies consciousness, aiding in neurological assessment and determining severity of brain injury.
#16
In a psychiatric emergency, what is the priority when assessing a patient's risk of harm to self or others?
Ensuring a safe environment
ExplanationEnsuring a safe environment is crucial to prevent harm to the patient or others, prioritizing safety.
#17
During a home visit, a nurse identifies a client taking multiple medications with potential interactions. What is the appropriate nursing action?
Contact the healthcare provider to discuss medication reconciliation
ExplanationContacting the healthcare provider ensures safe medication management and prevents adverse drug interactions.
#18
In a maternity unit, which assessment finding requires immediate attention in a postpartum woman?
Decreased blood pressure
ExplanationDecreased blood pressure postpartum may indicate hemorrhage or other complications requiring urgent intervention.
#19
During a neurological assessment, what is the primary purpose of assessing cranial nerve VII (Facial nerve) function?
Observing facial symmetry and expressions
ExplanationAssessing facial nerve function helps detect asymmetry or weakness, indicating neurological abnormalities.