Nokea
An autoclave is used to sterilize hospital supplies because:
- A. More articles can be sterilized at a time
- B. Steam causes less damage to the materials
- C. A lower temperature can be obtained
- D. Pressurized steam penetrates the supplies better
Correct Answer: D
Rationale: Pressurized steam enhances penetration, ensuring thorough sterilization.
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In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?
- A. A Glasgow Coma Scale score of 13
- B. Clear fluid leaking from the nose
- C. Nausea and vomiting
- D. Anisocoria
Correct Answer: B
Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.
What is an example of a subjective data?
- A. Heart rate of 68 beats per minute
- B. Yellowish sputum
- C. Client verbalized, 'I feel pain when urinating.'
- D. Noisy breathing
Correct Answer: C
Rationale: Subjective data consists of information reported by the patient, reflecting their personal experiences, sensations, or perceptions, which cannot be directly measured by the nurse. The statement 'I feel pain when urinating' is a classic example, as it conveys the patient's subjective sensation of pain, reliant on their verbal report rather than objective observation. This type of data is crucial for understanding symptoms like pain or discomfort that lack visible signs. In contrast, a heart rate of 68 beats per minute is objective, measurable via pulse check. Yellowish sputum and noisy breathing are also objective, observable through sight and sound during assessment. Subjective data, like the patient's pain report, enhances the nurse's ability to assess holistic needs, guiding further inquiry or intervention, such as checking for urinary tract issues, making it distinct from observable, objective findings.
Which intervention should the nurse implement to prevent contractures in a patient who is immobile?
- A. Encouraging frequent changes in position
- B. Applying heat packs to stiff joints
- C. Administering muscle relaxants
- D. Using soft restraints to immobilize the extremities
Correct Answer: A
Rationale: Frequent position changes prevent contractures in immobile patients by keeping joints mobile and reducing muscle shortening risks. Heat or relaxants offer relief but don't address root immobility, and restraints worsen stiffness. Nurses use this to maintain range of motion, ensuring flexibility and function, a proactive measure against permanent musculoskeletal damage in prolonged stillness.
A client with diverticulitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of high-fiber foods.
- B. I should decrease my intake of high-fiber foods.
- C. I should increase my intake of high-fat foods.
- D. I should decrease my intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A. Increasing intake of high-fiber foods is essential in managing diverticulitis as it helps prevent constipation and promotes bowel regularity, reducing the risk of complications and improving overall colon health. Choice B is incorrect because decreasing high-fiber foods can worsen diverticulitis symptoms. Choices C and D are also incorrect as increasing high-fat foods can exacerbate diverticulitis, while decreasing high-fat foods is generally recommended to manage the condition.
When is the best time to collect urine specimen for routine urinalysis and C/S?
- A. Early morning
- B. Later afternoon
- C. Midnight
- D. Before breakfast
Correct Answer: A
Rationale: Early morning urine first void e.g., concentrated is best for urinalysis/C&S, detecting glucose, bacteria. Later dilutes; midnight, pre-breakfast vary. Nurses collect e.g., 6 AM for accuracy, per protocols.