Nokea
A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse implement?
- A. Protect cornea with lubricant and eye shields
- B. Administer artificial tears every hour.
- C. Encourage the client to blink every 10 minutes.
- D. Keep the client's eyes closed with adhesive tape.
Correct Answer: A
Rationale: Lack of blinking increases the risk of corneal damage. Lubricants and eye shields prevent dryness and injury to the cornea.
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A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?
- A. Allow additional time to complete physical activities to reduce oxygen demand
- B. Practice inhaling through the nose and exhaling slowly through pursed lips
- C. Use a humidifier to increase home air quality humidity between 30-50%
- D. Strengthen abdominal muscles by alternating leg raises during exhalation
Correct Answer: B
Rationale: Pursed-lip breathing helps improve oxygenation and reduce dyspnea in clients with emphysema.
An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure?
- A. The foster mother
- B. The social worker who placed the infant in the foster home
- C. The registered nurse caring for the infant
- D. The nurse-manager
Correct Answer: A
Rationale: The foster mother, as the primary caregiver, is typically authorized to provide consent for medical procedures.
Clinical manifestations of haemophilia include:
- A. Bleeding following neonatal intramuscular injection
- B. Intracranial bleeding
- C. Gingival bleeding
- D. Menorrhagia
Correct Answer: B
Rationale: Intracranial bleeding is a serious and potentially life-threatening manifestation of hemophilia, particularly in severe cases.
Regarding cough receptors:
- A. There is increased sensitivity in viral infections
- B. ~2-agonists decrease the sensitivity of cough receptors
- C. Exercise can stimulate the cough receptors in asthmatics
- D. They are predominantly seen in the large airways
Correct Answer: A
Rationale: Cough receptor sensitivity increases during viral infections, leading to heightened cough reflex.
The following are causes of cyanosis in the presence of 60% oxygen:
- A. Haemoglobin concentration < 5 g%
- B. Methaemoglobinaemia
- C. Thalassaemia
- D. Right to left shunt
Correct Answer: D
Rationale: A right-to-left shunt can cause cyanosis even in the presence of high oxygen levels. Methaemoglobinaemia and severe anemia (Hb < 5 g%) can also cause cyanosis.