Nokea
An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. inability to turn, cough, and breathe deeply
- B. inability to communicate pain
- C. inability to ambulate freely
- D. inability to use a bedside commode
Correct Answer: B
Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.
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The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
- A. The application of moist heat will alter tissue sensitivity by producing numbness.
- B. The application of moist heat will decrease the metabolic needs of the involved tissues.
- C. The application of moist heat will stop the local release of histamine in the tissues.
- D. The application of moist heat will increase blood flow and accelerate tissue healing.
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed at least 30 degrees.
- B. If the residual is greater than 200 mL, the LPN should not administer the enteral feeding.
- C. The residual should be discarded prior to administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct Answer: C
Rationale: The residual should be injected back into the PEG tube, as it contains important enzymes and nutrients.
The focus of a nurse case manager is:
- A. nursing care needs at discharge.
- B. the comprehensive care needs of the client for continuity of care.
- C. client education needs upon discharge.
- D. financial resources for needed care.
Correct Answer: B
Rationale: By definition, case management is a process of providing for the comprehensive care needs of a client for continuity of care throughout the health care experience.
Which of the following statements is true about syphilis?
- A. The cause and mode of transmission is unclear
- B. There is no known cure for the disease
- C. When the primary lesion heals, the disease is cured
- D. Syphilis can be cured with a course of antibiotic therapy
Correct Answer: D
Rationale: Syphilis is an acute and chronic treponemal disease that can be cured with antibiotics, such as a single IM dose of long-acting penicillin G (benzathine penicillin) for primary, secondary, or early latent syphilis. The cause and transmission (sexual contact) are clear, and healing of the primary lesion does not indicate a cure without treatment.
A wrong committed by one person against another (or against the property of another) that might result in a civil trial is:
- A. a tort.
- B. a crime.
- C. a misdemeanor.
- D. a felony.
Correct Answer: A
Rationale: Torts are wrongs committed by one person against another person (or against the property of another), which might result in civil trials. A crime is also defined as a wrong against a person or their property but is considered to be against the public as well. Misdemeanors are crimes that are commonly punishable with fines or imprisonment for less than one year, with both or with parole. A felony is a serious crime punishable by imprisonment in a State or Federal penitentiary for more than one year.