Nokea
A patient who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora?
- A. stool-softening laxatives, such as Colace
- B. increasing fluid intake to 3,000 mL/day
- C. drinking fluids with a high sugar content
- D. eating fermented products, such as yogurt
Correct Answer: D
Rationale: Yogurt's probiotics restore gut flora post-diarrhea.
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What is the normal fasting blood glucose range for a person who does not have diabetes?
- A. 46 to 78 mg/dl
- B. 70 to 100 mg/dl
- C. 105 to 120 mg/dl
- D. 115 to 132 mg/dl
Correct Answer: B
Rationale: The correct answer is B (70 to 100 mg/dl). This range is considered normal for a person without diabetes as it reflects healthy blood glucose levels. Values below 70 may indicate hypoglycemia, while values above 100 may indicate prediabetes or diabetes. Choice A is too low and suggestive of hypoglycemia. Choices C and D are too high and indicate hyperglycemia, which is not normal for someone without diabetes. Therefore, B is the correct answer based on the typical fasting blood glucose range for a healthy individual.
You are treating an adult trauma patient who was thrown from a moving vehicle. Upon assessment, you find the patient is hypotensive, has absent breath sounds on the right, and has visible tracheal deviation. What should you do first?
- A. Perform a needle decompression
- B. Administer a fluid bolus
- C. Intubate the patient
- D. Place the patient on a cardiac monitor
Correct Answer: A
Rationale: The correct answer is A: Perform a needle decompression. This is the first step because the patient likely has a tension pneumothorax, which is a life-threatening condition causing tracheal deviation, absent breath sounds, and hypotension. Needle decompression helps release the trapped air in the pleural space, alleviating the pressure on the heart and lungs. Administering a fluid bolus (choice B) may worsen the tension pneumothorax by increasing intrathoracic pressure. Intubation (choice C) may be necessary but should not be the first step in managing a tension pneumothorax. Placing the patient on a cardiac monitor (choice D) is important but not the immediate priority in this critical situation.
Which of the following statements is true of chest tubes?
- A. The drainage system must be kept above the level of the resident's chest.
- B. The chest drainage must be observed for amount and color.
- C. The tubing should be kinked.
- D. Chest tubes will only be in the front of the body
Correct Answer: B
Rationale: The correct answer is B because observing the amount and color of chest drainage is crucial to monitor the resident's condition and detect any complications. Changes in amount or color can indicate bleeding, infection, or other issues. This helps in assessing the effectiveness of the chest tube and determining the need for any interventions.
A is incorrect because the drainage system should be kept below the level of the resident's chest to facilitate drainage.
C is incorrect as tubing should never be kinked as it can obstruct the flow of drainage, leading to complications.
D is incorrect as chest tubes can be placed in various locations, not just in the front of the body.
Private law or a law between individuals is
- A. Criminal law
- B. Civil law
- C. Contract law
- D. International law
Correct Answer: B
Rationale: The correct answer is B: Civil law. Private law governs the relationships between individuals and organizations, dealing with matters such as contracts, property, and family law. Civil law is the branch of law that covers private law issues, making it the most appropriate choice. Criminal law (A) pertains to offenses against the state, not private disputes. Contract law (C) is a specific area within civil law that focuses on agreements between parties. International law (D) deals with the relations between states, not private individuals. Hence, civil law is the correct answer for private law.
The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take?
- A. Encourage copious amounts of water.
- B. Start an additional intravenous (IV) line.
- C. Measure and record all intake and output.
- D. Weigh the patient and compare with preoperative weight.
Correct Answer: C
Rationale: The correct answer is C: Measure and record all intake and output. This action is most appropriate for monitoring fluid and electrolyte balance in a postoperative patient as it helps to assess if the patient is receiving adequate fluids and excreting appropriately. By measuring and recording intake and output, the nurse can identify any imbalances and take necessary interventions.
Encouraging copious amounts of water (A) without monitoring intake and output can lead to fluid overload or imbalance. Starting an additional IV line (B) may not be necessary if the patient's current IV is functioning properly. Weighing the patient and comparing with preoperative weight (D) is important but may not provide real-time information on fluid and electrolyte balance.