The patient comes to the hospital with a variety of symptoms.
Which symptom will the nurse assess first?

Joint stiffness after sitting for a long period of time.

Nausea with a small amount of vomitus earlier this morning.

A rash that developed after the second dose of antibiotics.

Shortness of breath with audible wheezing.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Joint stiffness after sitting for a long period of time, often referred to as "gelling," is a common symptom associated with inflammatory joint conditions like osteoarthritis or rheumatoid arthritis. While it can be a source of discomfort and reduced mobility, it typically does not indicate an immediate life-threatening situation. The body's synovial fluid thins with inactivity, leading to increased friction and stiffness upon movement.

Choice B rationale

Nausea with a small amount of vomitus suggests gastrointestinal upset. While it can cause discomfort and lead to dehydration if persistent, it is generally not an acute emergency unless accompanied by severe abdominal pain, signs of dehydration, or other systemic symptoms. The body's chemoreceptor trigger zone can be activated by various stimuli, leading to the sensation of nausea and subsequent emesis.

Choice C rationale

A rash that developed after a second dose of antibiotics could indicate an allergic reaction, which ranges from mild to severe. While allergic reactions require assessment and intervention, they are not immediately life-threatening unless accompanied by signs of anaphylaxis such as angioedema or respiratory distress. This hypersensitivity reaction involves the immune system's response to the drug as an antigen.

Choice D rationale

Shortness of breath with audible wheezing indicates respiratory distress, which is a critical and potentially life-threatening condition. Wheezing suggests airway narrowing, which impedes oxygen-carbon dioxide exchange. Immediate assessment and intervention are required to prevent respiratory arrest and ensure adequate oxygenation to vital organs. This physiological response reflects bronchoconstriction and inflammation, severely compromising ventilation.

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Correct Answer is A

Explanation

Choice A rationale

Positioning a school-aged child in the supine position with the head tilted backward during nose drop administration allows gravity to assist the medication in flowing into the nasal cavity and reaching the intended mucosal surfaces. This anatomical alignment ensures optimal distribution and absorption of the drug, maximizing its therapeutic effect on the nasal passages.

Choice B rationale

Instructing the child to breathe deeply through the nose immediately after drop insertion could cause the medication to be inhaled into the lungs or swallowed, reducing its intended topical effect on the nasal mucosa. Proper technique involves maintaining the head position for a few moments to allow absorption.

Choice C rationale

Returning unused nose drops from the dropper to the medication bottle is an unsafe practice that can lead to contamination of the entire medication supply. The dropper tip, once it has touched the patient's nostril, is no longer sterile and can introduce microbes into the sterile solution.

Choice D rationale

Positioning the tip of the medication dropper within a nostril can cause discomfort, irritation, or even injury to the delicate nasal mucosa. The dropper should be held just above the nostril, allowing the drops to fall into the nasal passage without direct contact, ensuring patient safety and comfort.

Correct Answer is ["25"]

Explanation

Step 1 is to determine the total infusion time in minutes. 1 L = 1000 mL. 1000 mL ÷ (150 mL/h) = 6.666. hours. 6.666. hours × (60 min/hour) = 400 minutes.

Step 2 is to calculate the flow rate in drops per minute. (1000 mL ÷ 400 min) × (10 gtts/mL) = 25 gtts/min. The flow rate is 25 gtts/min.

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The patient comes to the hospital with a variety of symptoms. Which symptom will the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is to administer one nose drop to each nostril of a school-aged child. Which action should the nurse perform as part of this procedure?

Correct Answer is A

Explanation

The MD orders 1 L of LR to infuse at 150 mL/h for a post-op patient. The tubing drop factor is 10gtts/mL. Calculate the flow rate in drops per minute. (ROUND TO WHOLE NUMBER, LABEL CORRECTLY TO RECEIVE CREDIT)

Correct Answer is ["25"]

Explanation

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The patient comes to the hospital with a variety of symptoms.
Which symptom will the nurse assess first?