Nokea
When is sterile technique used?
- A. During strict isolation procedures
- B. After terminal disinfection is performed
- C. For invasive procedures
- D. When protective isolation is necessary
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?
- A. Hemoglobinuria
- B. Chest pain
- C. Urticaria
- D. Distended neck veins
Correct Answer: A
Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.
A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8°F (37.7°C). This temperature reading probably indicates:
- A. Infection
- B. Hypothermia
- C. Anxiety
- D. Dehydration
Correct Answer: D
Rationale: A patient being kept off food and fluids before surgery can lead to dehydration. Dehydration can cause a slight increase in body temperature, which could explain the elevated oral temperature reading of 99.8°F (37.7°C) in this scenario. Infections are more likely to cause higher fevers, hypothermia would present with a lower temperature, and anxiety typically does not directly affect body temperature in this manner.
A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:
- A. Ineffective airway clearance related to thick, tenacious secretions.
- B. Ineffective airway clearance related to dry, hacking cough.
- C. Ineffective individual coping with COPD.
- D. Pain related to immobilization of affected leg.
Correct Answer: A
Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.
Which of the following substances increase the amount of urine produced?
- A. Caffeine-containing drinks, such as coffee and cola
- B. Beets
- C. Urinary analgesics
- D. Kaolin with pectin (Kaopectate)
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following procedures always requires surgical asepsis?
- A. Vaginal instillation of conjugated estrogen
- B. Urinary catheterization
- C. Nasogastric tube insertion
- D. Colostomy irrigation
Correct Answer: B
Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.