Nokea
A client who is unconscious needs frequent mouth care. When performing mouth care, what is the best position for the client?
- A. Fowler's position
- B. Side-lying
- C. Supine
- D. Trendelenburg
Correct Answer: B
Rationale: When providing mouth care to an unconscious client, the side-lying position is the best choice. This position helps prevent aspiration by allowing any fluids to drain out of the mouth easily, reducing the risk of choking or aspiration pneumonia. Placing the client in a side-lying position also promotes comfort and safety during the procedure.
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For administering a cleansing enema, what is the common position typically used?
- A. Sims left lateral
- B. Dorsal Recumbent
- C. Supine
- D. Prone
Correct Answer: A
Rationale: The correct position for administering a cleansing enema is the Sims left lateral position. This position is preferred as it helps to facilitate the procedure by allowing gravity to assist in the flow of the enema solution. The individual lies on their left side with the right knee flexed towards the chest, which helps to promote retention of the enema solution and its distribution throughout the colon.
What is the best description of resonance?
- A. Sounds created by air-filled lungs
- B. Short, high-pitched, and thudding
- C. Moderately loud with a musical quality
- D. Drum-like
Correct Answer: A
Rationale: Resonance refers to the quality of sound produced by vibrations that are reinforced by other vibrations of the same frequency. In the context of the human body, resonance is often associated with sounds produced by air-filled structures like the lungs, vocal cords, and resonating cavities. Therefore, the best description of resonance from the given options is 'Sounds created by air-filled lungs.' This choice aligns with the concept of resonance as it relates to sound production in the human body.
What is the initial technique used when examining a client's abdomen?
- A. Palpation
- B. Auscultation
- C. Percussion
- D. Inspection
Correct Answer: D
Rationale: When examining a client's abdomen, the initial technique used is inspection. Inspection involves visually assessing the abdomen for any abnormalities, such as distention, scars, or rashes. This step allows the healthcare provider to gather valuable information before proceeding to other examination techniques like palpation, auscultation, and percussion.
After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client's vital signs. What phase of the nursing process is being implemented by the nurse?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
Correct Answer: A
Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process.
In which of the following organs does the exchange of gases take place?
- A. Kidneys
- B. Lungs
- C. Liver
- D. Heart
Correct Answer: B
Rationale: The exchange of gases, specifically oxygen and carbon dioxide, occurs in the lungs. In the lungs, oxygen from the air we breathe enters the bloodstream, while carbon dioxide is removed from the bloodstream and exhaled. This process is essential for respiration and supplying the body with oxygen for energy production.