CORRECT ANSWER: ARATIONALE: The nurse volunteer nurse is liable including the head nurse and the hospital based on the principleof respondeat superior.6.Daniel with multiple myeloma complains of deep bone pain. As his nurse, which of the following will you doFIRST?A.Assess bone painB.Administer prescribed analgesicC.Teach pain relief strategiesD.Support position with pillowCORRECT ANS: DRATIONALE: Independent intervention, promotes relaxation thus reducing pain and painful stimuli.OTHER OPTIONS:A - Late intervention. Remember the patient is in pain. Assessment is of No value.B – May follow after if the pain still exists.C – Patient in pain may not able to learn the pain relief strategies. Should be done when pain is not present.7.You are reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory result should youexpect to find?A.Increased platelet countB.Altered blood urea nitrogen (BUN) and creatinine levelsC.Electrolyte imbalanceD.Elevated erythrocyte sedimentation rate (ESR)CORRECT ANS: DRATIONALE:
Increased rate seen in inflammation and necrotic processes. An increase is often seen in anyinflammatory connective tissue disease, often indicating increased inflammation and resulting inclustering of RBCs, which makes them heavier than normal. The higher the sedimaentation rate, thegreater the inflammatory activity.
ESR is particularly useful as a guide to the management of the client with RA.(Source: Medical Surgical Nursing 7
edition; Black & Hawks)OTHER OPTIONS:A.Increased Platelet Count – may indicate hemorrhage, infectious disorders, malignancies, IDA, recent surgery,recent pregnancy, recent splenoctomy, inflammatory disorders, fractures, cryoglobulinemia, asplenia,asphyxiation, rheumatoid arthritis, heart disease, cirrhosis, chronic pancreatitis, TB, recovery from bonemarrow depression, multiple myeloma, primary thrombocytosis, myelofibrosis with myeloid metaplasia,polycythemia vera, or chronic myelogenous leukemia.B.BUN – Measures renal function and hydration. CREATININE – this blood test helps in the diagnosis of muscular diseases or trauma as well as MI.C.Electrolyte Imbalance – Usually for Fluid and Electrolyte disorders.8.Mrs. Paras is receiving total parenteral nutrition (TPN). If you will evaluate her nutritional status, which of thefollowing indicators will tell you that TPN was effective?A.Laboratory work upB.Adequate hydrationC.Weight gainD.Diminish episode of nausea and vomitingCORRECT ANS: ARATIONALE: Laboratory work up is done to assess levels of serum albumin, total protein, transferring,prealbumin, trigycerides, glucose, and urine nitrogen balance. It is also done in the assessment phase prior toadministration of TPN to provide baseline measures of nutritional status and blood glucose levels.(Source: Mosby’s Nursing interventions and clinical skills 3
edition; Elkin, Perry, Potter; pp. 904-905)OTHER OPTIONS:B, C, D – inadequate indicators in measuring the effectivity of TPN.9.While Jayvee, a burn patient is being transferred from the burn unit to the operating room, the IV bottle fell onJayvee's head. He sustained a laceration on his forehead. The nurse was proven guilty of negligence. Which of the following did the nurse fail to do?A.Hold the IV bottleB.Check the IV standC.Place the IV stand on the foot part of the stretcher D.Restrain JayveeCORRECT ANS: B
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