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A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)
- A. Ambulating a patient
- B. Inserting a feeding tube
- C. Performing resuscitation
- D. Documenting wound care
Correct Answer: A
Rationale: The correct answer is A: Ambulating a patient. Direct care interventions involve hands-on activities directly impacting patient outcomes. Ambulating a patient is a direct care intervention as it involves physically assisting the patient to move, promoting circulation, preventing complications, and improving overall well-being. Inserting a feeding tube (B) and performing resuscitation (C) are also direct care interventions as they involve immediate patient care actions. Documenting wound care (D) is not a direct care intervention as it involves recording information about a care activity rather than physically performing the care itself.
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Which part of the body is supplied by nerves form the thoracic cord?
- A. Head
- B. Pelvis
- C. Trunk
- D. Coccyx
Correct Answer: C
Rationale: The correct answer is C: Trunk. The thoracic cord supplies nerves to the trunk region of the body. The thoracic spinal nerves innervate the chest, abdomen, and back. They control sensation and movement in these areas. The head (A) is mainly supplied by cranial nerves, the pelvis (B) is innervated by lumbar and sacral nerves, and the coccyx (D) is supplied by the sacral nerves. Therefore, the correct answer is C as it aligns with the anatomical distribution of the thoracic spinal nerves.
Severe and extensive hemolysis causes which of the ff?
- A. Leg ulcers
- B. Shock
- C. Priapism
- D. Compromised growth
Correct Answer: B
Rationale: Severe and extensive hemolysis leads to the release of large amounts of hemoglobin into the bloodstream, causing hemoglobinemia. This can result in hemoglobinuria, leading to acute renal failure and ultimately shock. Shock is the correct answer as it is a severe consequence of extensive hemolysis. Leg ulcers (A) may occur in conditions like peripheral arterial disease. Priapism (C) is unrelated to hemolysis. Compromised growth (D) is not a common consequence of hemolysis.
What does a nurse assess postoperatively in a client with a nasal fracture?
- A. Allergic reaction
- B. Extreme sense of smell
- C. Airway obstruction
- D. Stridor
Correct Answer: C
Rationale: The correct answer is C: Airway obstruction. Postoperatively, a nurse must assess for airway patency in a client with a nasal fracture to ensure proper breathing. Any swelling or bleeding in the nasal area can lead to airway obstruction, which is a critical concern that needs immediate intervention. Choices A, B, and D are incorrect because an allergic reaction, extreme sense of smell, and stridor are not typically associated with postoperative assessment of a nasal fracture. It is crucial to prioritize airway assessment to prevent any complications related to breathing difficulties in this situation.
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
- A. Anticipatory grieving
- B. Disturbed body image
- C. Impaired swallowing
- D. Chronic low self-esteem
Correct Answer: A
Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life.
Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.
for pain management. When applying a new system, the nurse should:
- A. Press the system in place for 30 to 60 seconds.
- B. Choose a site on the lower torso.
- C. Shave the application site before use.
- D. Apply the system immediately after removal from a package.
Correct Answer: A
Rationale: Rationale:
A: Pressing the system in place for 30 to 60 seconds helps ensure proper adhesion and absorption of the medication. This step is crucial for the effectiveness of the pain management system.
B: Choosing a site on the lower torso is not necessary for applying the system. The site selection should be based on guidelines and patient preference.
C: Shaving the application site is not recommended unless specifically indicated. It is not a standard step for applying a pain management system.
D: Applying the system immediately after removal from a package may not allow the adhesive to fully activate, affecting its efficacy. It is important to follow the recommended steps for proper application.