Nokea
Prior to a thoracentesis, what intervention should the nurse complete?
- A. Measure oxygen saturation before and after the procedure.
- B. Verify that the client has given informed consent.
- C. Explain the procedure briefly to the client and their family.
- D. Ensure informed consent has been obtained from the client.
Correct Answer: D
Rationale: The correct answer is D because ensuring informed consent is crucial before any invasive procedure to protect the client's autonomy and rights. This involves confirming the client's understanding of the procedure, risks, benefits, and alternatives. Option B is correct as it directly relates to the ethical and legal aspect of the procedure. Option A is incorrect as it focuses solely on monitoring oxygen saturation, which is important but not the priority before thoracentesis. Option C is incorrect as simply explaining the procedure does not ensure the client's understanding or consent.
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Place the steps of the evidence-based practice (EBP) process in order (0 being the first step; 6 being the last step).
- A. Create a spirit of inquiry
- B. Ask a clinical question
- C. Critically analyze the evidence
- D. Make recommendations for practice or generate data
Correct Answer: B
Rationale: The EBP process begins with creating a spirit of inquiry, followed by asking a clinical question, finding and analyzing evidence, making recommendations, and evaluating outcomes.
A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height & weight
- D. Occupation & hobbies
Correct Answer: D
Rationale: The correct answer is D: Occupation & hobbies. This information is crucial as certain occupations or hobbies may expose the client to respiratory hazards, influencing their respiratory status. The healthcare professional needs to assess potential respiratory risks in the client's environment.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status assessment.
B: Neck circumference is more relevant for assessing risk of obstructive sleep apnea rather than overall respiratory status.
C: Height & weight are important for assessing overall health and potential respiratory issues like obesity, but not as immediate as assessing respiratory hazards in the client's daily activities.
Which manipulative and body-based technique uses pressure applied to the feet and hands?
- A. Massage
- B. Reflexology
- C. Shiatsu
- D. Chiropractic technique
Correct Answer: B
Rationale: Reflexology applies pressure to specific points on the feet and hands, stimulating corresponding body areas.
Total parenteral nutrition(TPN), is one of the home therapies being used for Chelsea Mann, 35, with acute ulcerative colitis causing massive diarrhea. She and her family will need instruction about:
- A. caring for the central catheter.
- B. how to mix the TPN solution.
- C. fixing malfunctions occuring in the IV pump.
- D. teaching the neighbors how to care for her.
Correct Answer: A
Rationale: Prevention of infection, and potential septicemia, is of prime importance for someone with a central catheter. Mixing TPN is a very specialized procedure, and should be done under laminar airflow by a pharmacist. IV pumps are machines that do malfunction, but the safest thing to do would be to get the manufacturer to do the repair. Having neighbors be a support to Chelsea and her family may not be possible. More information would be necessary prior to choosing this as an option for a nursing diagnosis.
What best describes Mrs. West’s change in vital signs postoperatively?
- A. Decrease in BP indicates shock is imminent
- B. Elevated temperature indicates wound infection
- C. Decrease in BP is consistent with hypertension
- D. Elevation in temperature is consistent with normal postoperative recovery
Correct Answer: D
Rationale: A mild fever is common after surgery due to inflammatory response.