Nokea
Being in contact with reality and the environment is a function of the:
- A. conscience
- B. ego
- C. id
- D. super ego
Correct Answer: B
Rationale: Being in contact with reality and the environment is a function of the ego. The ego is responsible for mediating between the id's basic desires, the superego's idealistic standards, and the real world. The conscience (not listed as a choice) is related to feelings of guilt or moral responsibility. The id represents primal instincts, and the superego represents the internalized ideals and moral standards.
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What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?
- A. Sensation of taste
- B. Sensation of pressure
- C. Sensation of smell
- D. Urge to defecate
Correct Answer: B
Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.
During the first 24 hours after the thermal injury, you should assess Sergio for:
- A. hypokalemia and hypernatremia
- B. hypokalemia and hyponatremia
- C. hyperkalemia and hyponatremia
- D. hyperkalemia and hypernatremia
Correct Answer: D
Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.
In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?
- A. Instruct the client to observe strict bed rest
- B. Check for epidural catheter drainage
- C. Administer analgesia through the epidural catheter as prescribed
- D. Assess respiratory rate carefully
Correct Answer: D
Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.
All of the following are contraindications when giving Immunization except:
- A. BCG Vaccine can be given to a child with AIDS
- B. BCG Vaccine can be given to a child with Hepatitis B
- C. DPT can be given to a child that had convulsion 3 days after being given the first DPT dose
- D. DPT can be given to a child with active convulsion or other neurological disease
Correct Answer: B
Rationale: The correct answer is B. BCG vaccine can be given to a child with Hepatitis B, as there is no contraindication for this. Choice A, C, and D all present contraindications for administering immunizations. Choice A is incorrect because giving BCG vaccines to a child with AIDS is a contraindication. Choice C is incorrect as convulsions after the first DPT dose indicate a contraindication to subsequent doses. Choice D is incorrect because active convulsions or other neurological diseases are contraindications to receiving the DPT vaccine.
Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. You, as the RN, will make sure that the family knows to:
- A. offer pureed foods
- B. offer soft foods for a week to minimize discomfort while swallowing
- C. supplement his diet with Vitamin C-rich foods to enhance healing
- D. offer clear liquids for 3 days to prevent irritation
Correct Answer: B
Rationale: After tonsillectomy and adenoidectomy, it is crucial to provide soft foods for a week to minimize discomfort while swallowing. This helps prevent irritation to the surgical site and allows for easier healing. Offering pureed foods (Choice A) may not be necessary as soft foods are usually sufficient. While Vitamin C is beneficial for healing, it is not necessary to supplement it immediately after surgery with Vitamin C-rich juices (Choice C). Clear liquids are typically recommended before surgery and not after, as the focus shifts to soft foods to aid in recovery, making Choice D incorrect.