The normal range of hemoglobin in the blood of an adult:
- A. 7-11 mg
- B. 14-20 mg
- C. 12-18 mg
- D. 20-26 mg
Correct Answer: C
Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.
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Which of the ff. would the nurse explain to the patient is indicated by a Snellen chart finding 20/80?
- A. The eye can see at 80 feet what the normal eye can see at 20 feet.
- B. The eye can see at 20 feet what the normal eye can see at 80 feet.
- C. The eye can see four times what the normal eye can see.
- D. The eye sees normally.
Correct Answer: B
Rationale: The correct answer is B because a Snellen chart reading of 20/80 means the patient can see at 20 feet what a normal eye can see at 80 feet. This indicates that the patient's vision is below average. Choice A is incorrect because it reverses the numerator and denominator. Choice C is incorrect because it does not accurately represent the Snellen chart findings. Choice D is incorrect because 20/80 is not considered normal vision.
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James’ neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow.
Incorrect choices:
B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties.
C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties.
D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.
In assessing a post mastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:
- A. Accepting the denial.
- B. Supporting the denial.
- C. Confronting the denial.
- D. Interpreting the denial.
Correct Answer: C
Rationale: The correct response is C: Confronting the denial. Denial is a defense mechanism that can hinder the client's acceptance and coping with the situation. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and process their feelings. Accepting (A) or supporting (B) the denial would enable the client to avoid facing reality. Interpreting (D) the denial may lead to miscommunication or misunderstanding. Confronting the denial encourages the client to address their emotions and move towards acceptance and healing.
The initial neurological symptom of Guilain-Barre Syndrome is:
- A. Absent tendon reflex
- B. Paresthesia of the legs
- C. Dysrhythmias
- D. Transient hypertension Toni a 32 year old mother of two has had multiple sclerosis for 5 years. She is currently enrolled in a school of nursing. Her husband is supportive and helps with care of their preschool sons. Toni has been admitted to the clinical area for diagnostic studies related to symptoms of visual disturbances.
Correct Answer: B
Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs.
Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS.
Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom.
Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation.
In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.
A 57-year old patient had a right lower lobectomy. The nurse should initiate this action when the patient arrives from the Post Anesthesia Care Unit:
- A. immediately administer pain relief
- B. keep patient in semi-fowler’s postion
- C. turn client every hour
- D. notify the family to report pateint’s condition
Correct Answer: A
Rationale: The correct answer is A: immediately administer pain relief. After a lobectomy, the patient may experience significant pain due to the surgical incision and chest tube insertion. Providing prompt pain relief is crucial to ensure the patient's comfort and prevent complications such as shallow breathing or limited mobility. This action will also aid in the patient's early recovery and promote better outcomes.
Choice B (keep patient in semi-fowler's position) is not the priority upon arrival from the Post Anesthesia Care Unit as pain management takes precedence. Choice C (turn client every hour) is important for preventing complications but is not the immediate action required upon arrival. Choice D (notify the family to report patient's condition) is important but not as urgent as providing pain relief to the patient.