Nokea
A community health nurse is assessing client's urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?
- A. The nurse added the Urine as the 2/3 part of the solution
- B. The nurse heats the test tube after adding 1/3 part acetic acid
- C. The nurse heats the test tube after adding 2/3 part of Urine
- D. The nurse determines abnormal result if she noticed that the test tube becomes cloudy
Correct Answer: B
Rationale: Acetic acid tests protein cloudiness not glucose; heating only acid (no urine) is wrong. Urine (2/3), heating with urine, cloudiness (protein) are correct. Nurses need correction e.g., purpose for accuracy, per procedure.
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The nurse is teaching a client who underwent a hypophysectomy for hypopituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.
- A. Nose blowing
- B. Teeth brushing
- C. Bending forward
- D. Lying in a semi-Fowler's position
Correct Answer: A
Rationale: Post-hypophysectomy, nose blowing (A) risks CSF leak or meningitis by disrupting the surgical site. Brushing (B) and semi-Fowler's (D) are safe. Bending (C) is risky but less immediate. A is correct. Rationale: Nasal pressure can breach the pituitary fossa repair, a critical complication in early recovery, per post-operative neurosurgery care, unlike benign actions.
A client with chronic obstructive pulmonary disease (COPD) is prescribed long-term oxygen therapy. What is the most important nursing consideration for this client?
- A. Assessing for signs of oxygen toxicity
- B. Monitoring the client's carbon dioxide levels
- C. Promoting proper humidification of oxygen
- D. Ensuring an adequate supply of oxygen
Correct Answer: B
Rationale: Monitoring carbon dioxide levels (B) is critical in COPD clients on long-term oxygen therapy, as they may retain CO2, risking respiratory acidosis if oxygen suppresses their hypoxic drive (target SpO2 88-92%). Oxygen toxicity (A) is rare at low flows used in COPD. Humidification (C) enhances comfort but isn't the priority. Oxygen supply (D) is a general need, not COPD-specific. CO2 monitoring via ABGs or capnography ensures safe titration, preventing hypercapnia, a key consideration per COPD management guidelines like GOLD standards.
Which of the following statement best describe a health care proxy?
- A. A medical diagnosis
- B. A person chosen to decide
- C. A hospital policy
- D. A treatment plan
Correct Answer: B
Rationale: A health care proxy is a person chosen to decide (B), per definition e.g., surrogate for incapacity. Not diagnosis (A), policy (C), plan (D) decision-maker. B best defines proxy's role, like Mr. Gary appointing someone, making it correct.
Which of the following statement best describe quality improvement?
- A. A one-time fix
- B. Ongoing effort to enhance care
- C. A punishment for errors
- D. A financial strategy
Correct Answer: B
Rationale: Quality improvement is an ongoing effort to enhance care (B), per QI models e.g., PDSA cycles. Not one-time (A), not punishment (C), not just finance (D) continuous. B best defines QI's iterative nature, making it correct.
Anaphylactic reaction after administering penicillin indicates
- A. An acquired atopic sensitization
- B. Passive immunity to penicillin allergen
- C. Antibodies to penicillin developed after earlier use of the drug
- D. Developed potent bivalent antibodies when the IV administration was started
Correct Answer: C
Rationale: Anaphylaxis is a severe IgE-mediated allergic reaction, occurring when prior penicillin exposure sensitizes the immune system, forming antibodies. Re-exposure triggers histamine release, causing symptoms like shock or dyspnea. Atopic sensitization relates to predisposition, not specific drug history. Passive immunity involves transferred antibodies, not self-developed ones. Bivalent antibodies forming during IV use is incorrect sensitization precedes administration. Nurses must assess allergy history, preparing for emergencies like epinephrine administration to reverse this life-threatening response.