Nokea
A nurse is explaining to the nursing students working on the antepartum unit how to assess for edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? N R I G B.C M U S N T O
- A. +1
- B. +2
- C. +3
- D. 4
Correct Answer: C
Rationale: Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as
+1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities
is +2 edema. Generalized massive edema (+4) includes the accumulation of fluid in the
peritoneal cavity.
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A nurse is caring for a patient who has allergic rhinitis. What intervention would be most likely to help the patient meet the goal of improved breathing pattern?
- A. Teach the patient to take deep breaths and cough frequently.
- B. Use antihistamines daily throughout the year.
- C. Teach the patient to seek medical attention at the first sign of an allergic reaction.
- D. Modify the environment to reduce the severity of allergic symptoms.
Correct Answer: D
Rationale: Allergic rhinitis, also known as hay fever, is a condition characterized by inflammation in the nasal passages triggered by allergens such as pollen, dust mites, or animal dander. Modifying the patient's environment to reduce exposure to these allergens can significantly help improve the breathing pattern in patients with allergic rhinitis. This can include measures such as using air purifiers, keeping indoor humidity levels low, avoiding exposure to pollen by keeping windows closed during peak seasons, and regularly cleaning bedding to reduce dust mites.
A patient has a history of drug use and is screened for hepatitis B during the first trimester. Which action is most appropriate?
- A. Practice respiratory isolation.
- B. Plan for retesting during the third trimester.
- C. Discuss the recommendation to bottle feed her baby.
- D. Anticipate administering the vaccination for hepatitis B as soon as possible
Correct Answer: B
Rationale: A person who has a history of high-risk behaviors, such as drug use, should be retested for hepatitis B during the third trimester. This is because the virus can have a long incubation period before showing up in blood tests. Retesting in the third trimester ensures that if the infection was acquired after the initial screening, it will be detected in time to provide appropriate care and interventions. Retesting is important in high-risk individuals to ensure proper management and prevention of hepatitis B transmission.
The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse?
- A. A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away.
- B. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.
- C. A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away.
- D. A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away.
Correct Answer: A
Rationale: A person whose vision is measured at 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. In this measurement system, the first number represents how far away the person is from the eye chart (the testing distance), and the second number indicates how far away a person with normal vision can be from the chart to see the same line of letters or objects. Therefore, if someone has 20/40 vision, it means they need to be at 20 feet to see what a person with 20/20 vision can see at 40 feet.
A nurse is evaluating a nursing assistive personnel’s(NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene?
- A. Emptying the drainage bag when half full
- B. Kinking the catheter tubing to obtain a urine specimen
- C. Placing the drainage bag on the side rail of the patient’s bed
- D. Securing the catheter tubing to the patient’s thigh
Correct Answer: C
Rationale: Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the other actions are correct procedures and do not require immediate follow-up. The drainage bag should be emptied when it is half full to prevent tension and pulling on the catheter, which could result in trauma to the urethra and increase the risk for urinary tract infections. Urine specimens are traditionally obtained by temporarily kinking the tubing, while securing the catheter tubing to the patient’s thigh prevents catheter dislodgment and tissue injury.
A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patients room?
- A. That a commode is always available at the bedside
- B. That all furniture remains in the same position
- C. That visitors do not leave items on the bedside table
- D. That the patients slippers stay under the bed
Correct Answer: B
Rationale: It is crucial for the nurse to monitor that all furniture remains in the same position in the hospitalized patient's room. For a patient with impaired vision who needs to create a mental picture of the room to mobilize independently and safely, any changes in the position of furniture can disrupt this mental map and potentially lead to accidents or falls. By ensuring that all furniture remains unchanged, the nurse supports the patient's ability to navigate the room confidently and without obstacles. This monitoring helps promote the patient's safety and independence during their stay in the hospital.