Answer to Question 1
D
Feedback
A The assessment of the buccal mucosa for cyanosis can be subjective in nature.
B The presence of cool, pale, clammy skin is an indicative finding associated with
hypovolemic shock.
C Hypovolemic shock is associated with lethargy, not restlessness.
D Hemorrhage may result in hypovolemic shock. Shock is an emergency situation
in which the perfusion of body organs may become severely compromised, and
death may occur. The presence of adequate urinary output indicates adequate
tissue perfusion.
Answer to Question 2
A
Feedback
A Children as young as 5 years old have effectively used PCA therapy. Further data
are needed to evaluate the use of PCA therapy in children younger than 5 years
of age.
B Two RNs are needed to check the amount of opioid being administered. Once
the opioid infusion is hung and programmed, a second RN must double-check
the process.
C Children receiving PCA therapy should be monitored closely to ensure effective
pain control and for signs or symptoms of overmedication. Initially, vital signs
should be monitored every 15 to 30 minutes and then every 2 to 4 hours.
Respiratory rate should be assessed every hour.
D Narcan should be readily available to reverse opioid overmedication exhibited by
respiratory distress.
NUrse
Nurse-patient interaction; nonveral communication
When using an interpreter, the nurse should pose questions directly to the patient, not the interpre
Acromegaly. Photo of a woman illustrating the enlarged skull, jaw, and hands typical of acromegaly.
Nurse using a stethoscope
Types of Shock