Nokea
During a Romberg test, the patient is asked to assume which position?
- A. Sitting
- B. Standing
- C. Genupectoral
- D. Trendelenburg
Correct Answer: B
Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.
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Which of the following measures is not recommended to prevent pressure ulcers?
- A. Massaging the reddened area with lotion
- B. Using a water or air mattress
- C. Adhering to a schedule for positioning and turning
- D. Providing meticulous skin care
Correct Answer: A
Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.
The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler's position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
- A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
- B. Place a humidifier in the patient's room
- C. Continue administering oxygen by high humidity face mask
- D. Perform chest physiotherapy on a regular schedule
Correct Answer: D
Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.
All of the following statements are true about donning sterile gloves except:
- A. The first glove should be picked up by grasping the inside of the cuff.
- B. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
- C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist.
- D. The inside of the glove is considered sterile.
Correct Answer: D
Rationale: When donning sterile gloves, it is essential to maintain sterility. The correct way to don sterile gloves includes grasping the outside of the cuff to put on the first glove and inserting the gloved fingers under the cuff outside the glove to put on the second glove. Adjustments should be made by sliding the fingers under the sterile cuff. It is crucial to remember that once the inside of the glove is touched during the donning process, it is no longer considered sterile.
Why is a precise amount of oxygen necessary for a patient with COPD to prevent which complication?
- A. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)
- B. Circulatory overload due to hypervolemia
- C. Respiratory excitement
- D. Inhibition of the respiratory hypoxic stimulus
Correct Answer: D
Rationale: In patients with COPD, the respiratory drive is often stimulated by low oxygen levels. Administering too much oxygen can inhibit this hypoxic drive, leading to respiratory depression and potential respiratory failure. Therefore, it is crucial to carefully regulate the oxygen therapy to prevent the inhibition of the respiratory hypoxic stimulus in COPD patients.
Which of the following conditions may necessitate fluid restriction?
- A. Fever
- B. Chronic Obstructive Pulmonary Disease
- C. Renal Failure
- D. Dehydration
Correct Answer: C
Rationale: Renal failure often necessitates fluid restriction to prevent fluid overload. In renal failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to fluid accumulation in the body. Restricting fluid intake helps manage this condition by preventing further fluid buildup and complications such as edema and electrolyte imbalances.