Nokea
How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Restraints must be released every 2 hours to assess circulation, skin integrity, and client comfort, with assessments every 30 minutes while restrained.
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A 27 year-old woman has delivered twins in the OB unit. The patient develops a condition of 5 centimeter diastasis recti abdominis. Which of the following statements is the most accurate when instructing the patient?
- A. Sit-ups are o.k. to do as long as you don't strain.
- B. This condition leads to surgery in $80 \%$ of cases.
- C. Guarding the abdominal region is important at this time.
- D. Antibiotics are required for this condition in $70 \%$ of patients.
Correct Answer: C
Rationale: Protection of the abdominal wall is critical at this point in time.
When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
- A. corner of the mouth to the tragus of the ear
- B. corner of the eye to the top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct Answer: A
Rationale: An oropharyngeal airway is measured from the corner of the client's mouth, to the tragus of the ear.
Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord?
- A. Brown-Séquard syndrome
- B. posterior cord syndrome
- C. central cord syndrome
- D. cauda equina syndrome
Correct Answer: A
Rationale: Brown-Séquard syndrome is a result of damage to one-half of the spinal cord. The other choices are also incomplete lesions of the spinal cord, but they have different defining characteristics.
A nurse is caring for a retired MD. The MD asks the question, 'What type of cells create exocrine secretions?'
- A. alpha cells
- B. beta cells
- C. acinar cells
- D. plasma cells
Correct Answer: C
Rationale: Acinar cells create exocrine secretions.
Which of the following might be an appropriate nursing diagnosis for an epileptic client?
- A. Dysreflexia
- B. Risk for Injury
- C. Urinary Retention
- D. Unbalanced Nutrition
Correct Answer: B
Rationale: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.