Nokea
Before administering oxygen to a patient, what should the nurse initially do?
- A. Observe the patient’s respiratory pattern
- B. Monitor the arterial blood gas results
- C. Determine if the patient has a history of COPD
- D. Ask the patient if he prefers nasal or mask O₂
Correct Answer: A
Rationale: Assessing respiratory effort helps tailor oxygen therapy appropriately.
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Three days after surgery, Mark notices that the wound site is more painful now than it was the day before. When you inspect the surgical site you are looking for redness or inflammation. Other indicators of infection would include:
- A. Elevated RBC and elevated respiratory rate.
- B. Elevated WBC and elevated temperature.
- C. Elevated erythrocyte sedimentation rate and decreased pulse.
- D. Decreased platelets and decreased blood pressure.
Correct Answer: B
Rationale: Elevated white blood cell (WBC) count and fever are classic signs of infection. These indicators suggest the body is mounting an immune response to a potential pathogen.
Why does the circulating nurse remove a tightly rolled blanket from under Mrs. West’s knees?
- A. Prevent damage to nerves and circulation
- B. Provide a flat surface for the sterile field
- C. Stretch lower leg muscles to prevent strain
- D. Facilitate access to the surgical site
Correct Answer: A
Rationale: Improper positioning can cause nerve compression and circulatory issues.
Which stage of wound healing lasts from 21 days to several months and even 1 to 2 years, allowing the strength of the wound to increase through synthesis of collagen by fibroblasts and lysis by collagenase enzymes?
- A. Inflammatory stage
- B. Proliferative phase
- C. Maturation phase
- D. Approximation phase
Correct Answer: C
Rationale: The correct answer is C because the maturation phase involves collagen remodeling and strengthening.
List the order for the actions that you must perform.
- A. Perform the chin lift or jaw thrust maneuver
- B. Establish unresponsiveness
- C. Initiate cardiopulmonary resuscitation (CPR)
- D. Call for help and activate the code team
Correct Answer: B
Rationale: Establishing unresponsiveness is the first step in assessing the patient's condition.
Several cultural groups avoid direct eye contact and consider it disrespectful or aggressive. Which cultural group may not return a direct gaze?
- A. Arab
- B. Asian
- C. Hispanic
- D. Native American
Correct Answer: B
Rationale: In many Asian cultures, avoiding direct eye contact signifies respect, particularly toward authority figures or elders.