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After routine patient contact, how long should hand washing last at least?
- A. 30 seconds
- B. 1 minute
- C. 2 minutes
- D. 3 minutes
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?
- A. Less than 30 ml/hour
- B. 64 ml in 2 hours
- C. 90 ml in 3 hours
- D. 125 ml in 4 hours
Correct Answer: A
Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.
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.
For abdominal inspection, in which of the following positions should a patient be placed?
- A. Prone
- B. Trendelenburg
- C. Supine
- D. Side-lying
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following patients is at greatest risk for developing pressure ulcers?
- A. An alert chronic arthritic patient treated with steroids and aspirin
- B. An 88-year-old incontinent patient with gastric cancer who is confined to bed at home
- C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
- D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed
Correct Answer: B
Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.
A 38-year-old patient's vital signs at 8 a.m. are axillary temperature 99.6°F (37.6°C); pulse rate 88; respiratory rate 30. Which findings should be reported?
- A. Respiratory rate only
- B. Temperature only
- C. Pulse rate and temperature
- D. Temperature and respiratory rate
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.