A patient with a history angina pectoris brought by to the Emergency Department complaining of severe chest pain. The patient informs the nurse that he did not take nitroglycerine tablet. Which of the following assessment findings must concern the nurses MOST before administering nitroglycerine?
A. Heart rate of 90 bpm
B. Blood sugar of 12 mmol/L
C. Blood pressure of 190/110 mmHg
D. Blood pressure of 80/60 mmHg
The nurse assesses a patient with Chronic Renal Failure notes crackles in the lung bases, elevated blood pressure, and weight gain of 1 kg in one day. Based on these finding, which of the following nursing diagnoses is the MOST appropriate for this patient?
A. Increased cardiac output related to fluid overload
B. Ineffective tissue perfusion related to interrupted arterial blood flow
C. Imbalance nutrition more than body requirements related to dietary excess
D. Excess fluid volume related to the kidney's inability to maintain fluid balance
The doctor heard a staff nurse saying "That doctor is incompetent". The doctor can file a complaint against the staff nurse for:
A. Libel
B. Assault
C. Slander
D. Malpractice
A nurse found two different readings while measuring a blood pressure for a client at primary health care.
According to the guideline of National Non-communicable Disease (NCD) screening program, which of the following is the BEST nurse's action?
A. Record the average of the reading
B. Record the highest reading for both arms
C. Ask the patient to lay down and check BP in both arms
D. Repeat blood pressure measurement and take the average of the two readings
A nurse is caring for a patient with retinal detachment who is posted for retinopexy surgery.
The INITIAL nursing intervention in order to maintain pressure for reattaching the sensory retina:
A. Keep the patient in prone position
B. Provide eye patch with intact dressing
C. Follow aseptic technique when cleaning the eye
D. Instruct the patient to avoid lying on the surgical side
A nurse plans to provide morning care for a bedridden client.
What is the priority action that the nurse should consider before starting?
A. Remove the pillows
B. Remove the bed sheets
C. Ensure that the bed is locked
D. Ensure that the client is at the side of the bed
An 11-year-old child with beta-thalassemia major is admitted for blood transfusion. The child underwent splenectomy last month. Which of the following is a PRIORITY nursing intervention?
A. Prevent infections
B. Promote high-fat intake
C. Encourage frequent voiding
D. Maintain adequate hydration
In a cardiotocogram (CTG) strip, the time from the beginning of one contraction to the end of the same contraction is called:
A. Duration
B. Frequency
C. Intensity
D. Range
While reviewing medication charts, the nurse observed that one patient received a wrong medication that was prescribed for another patient with similar first and last name. What is the BEST nursing action for reporting the incident?
A. The nurse states client's comment by using direct codes
B. The nurse should report and document the incident immediately
C. The nurse assesses client's vital signs and keep him under observation
D. The nurse reports the incident to senior nurse who assist writing the report
A nurse aims to establish a respectful therapeutic relationship with a patient. Which of the following actions is MOST appropriate to achieve this?
A. Discussing non-health-related topics
B. Being congruent between what is felt and what is expressed
C. Considering client's ideas, preferences, and opinions when planning care
D. Understanding the meaning and relevance of client's thoughts and feelings