Nokea
In the management process, the periodic checking of the results of action to make sure that it coincides with the goal of the institution is termed as:
- A. Planning
- B. Evaluating
- C. Directing
- D. Organizing
Correct Answer: B
Rationale: The correct answer is B: Evaluating. Evaluating involves the periodic checking of results to ensure they align with the institution's goals. Planning (choice A) is about setting goals and determining the actions required to achieve them. Directing (choice C) involves overseeing and guiding the activities of individuals or teams to accomplish goals. Organizing (choice D) is about arranging resources and tasks to achieve objectives. In the context of the management process described, evaluating best fits the action of checking results against goals.
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During which step of the nursing process does the nurse analyze data related to the patient's health status?
- A. Assessment
- B. Implementation
- C. Diagnosis
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is 'Assessment.' During the assessment phase of the nursing process, the nurse collects and analyzes data related to the patient's health status. This involves gathering information through various means such as patient interviews, physical examinations, and reviewing medical records. Choice B, 'Implementation,' refers to the phase where the nurse carries out the planned interventions. Choices C and D, 'Diagnosis' and 'Evaluation,' come after the assessment phase in the nursing process.
During the first 24 hours after the thermal injury, you should assess Sergio for:
- A. hypokalemia and hypernatremia
- B. hypokalemia and hyponatremia
- C. hyperkalemia and hyponatremia
- D. hyperkalemia and hypernatremia
Correct Answer: D
Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.
After cleaning the abrasions and applying antiseptic, the nurse applies a cold compress to the swollen ankle as ordered by the physician. This statement shows that the nurse has a correct understanding of the use of a cold compress:
- A. Cold compress reduces blood viscosity in the affected area
- B. It is safer to apply than a hot compress
- C. Cold compress prevents edema and reduces pain
- D. It eliminates toxic waste products due to vasodilation
Correct Answer: C
Rationale: The correct understanding of using a cold compress includes knowing that it helps prevent edema and reduces pain. Cold application constricts blood vessels, reducing blood flow to the area, which helps decrease swelling and pain. Choices A, B, and D are incorrect because cold compresses do not directly affect blood viscosity, safety compared to hot compresses, or eliminate toxic waste products due to vasodilation. It is essential for nurses to have a clear understanding of the rationale behind interventions to provide effective patient care.
After bronchoscopy, the nurse's priority is to check which of the following before feeding?
- A. Gag reflex
- B. Wearing off of anesthesia
- C. Swallowing reflex
- D. Peristalsis
Correct Answer: A
Rationale: After a bronchoscopy procedure, the nurse's priority is to check the patient's gag reflex before allowing them to eat to prevent aspiration. The gag reflex helps protect the airway by triggering a cough or gag response if something touches the back of the throat. This is crucial to ensure that the patient can protect their airway and prevent food or fluids from entering the lungs, especially when the throat may be sensitive or compromised post-bronchoscopy. Checking for the wearing off of anesthesia, swallowing reflex, or peristalsis are important assessments but not the immediate priority before feeding in this context.
What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?
- A. Sensation of taste
- B. Sensation of pressure
- C. Sensation of smell
- D. Urge to defecate
Correct Answer: B
Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.