Nokea
Correct method of mouth to mouth respiration is that the victim's chin is held:
- A. Forward
- B. Backward
- C. Sideward
- D. Downward
Correct Answer: D
Rationale: When performing the correct method of mouth-to-mouth respiration, it is essential to ensure that the victim's chin is held downward. This helps to properly open the airway, allowing for effective ventilation. By tilting the head back and holding the chin downward, you are able to align the victim's airway to allow the entry of air into the lungs during rescue breathing. Holding the chin in a downward position also helps prevent any obstruction that may hinder the flow of air. Remember to also pinch the victim's nose closed while giving breaths to ensure that the air goes into their lungs.
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The most likely cause of her chief complaint this morning is
- A. A decrease in postoperative stress causing poiyuria
- B. The onset of diabetes mellitus, an unusual complication
- C. An expected result of the removal of the pituitary gland
- D. A frequent complication of the hypophysectomy
Correct Answer: D
Rationale: The most likely cause of her chief complaint this morning is a frequent complication of the hypophysectomy. A hypophysectomy is the surgical removal of the pituitary gland. One common complication following a hypophysectomy is diabetes insipidus, characterized by polyuria (excessive urination) and polydipsia (excessive thirst). This occurs because the removal of the pituitary gland can disrupt the regulation of antidiuretic hormone (ADH), which plays a key role in maintaining water balance in the body. Therefore, it is the most likely cause of the patient's chief complaint of polyuria this morning.
A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?
- A. Deficient fluid volume related to osmotic diuresis
- B. Decreased cardiac output related to increased heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The highest priority nursing diagnosis in this scenario is Deficient fluid volume related to osmotic diuresis. The client's serum glucose level of 618mg/dl indicates severe hyperglycemia, which is likely causing osmotic diuresis leading to fluid volume deficit. The client's hot, dry skin, along with a heart rate of 116 beats/min, and blood pressure of 108/70mmHg are symptoms of dehydration due to fluid loss. If left untreated, deficient fluid volume can lead to serious complications such as hypovolemic shock. Therefore, addressing the fluid volume deficit is essential to stabilize the client's condition before other nursing diagnoses are addressed.
To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium:
- A. In patients who are unconscious
- B. In patients who show neurologic
- C. To prevent fluid overload symptoms
- D. To prevent dehydration
Correct Answer: C
Rationale: It is safer to restrict fluid intake rather than administer sodium to return a patient with hyponatremia to normal sodium levels to prevent fluid overload symptoms. Restoring normal sodium levels in patients with hyponatremia requires caution to prevent rapid correction which can lead to osmotic demyelination syndrome. By restricting fluid intake, the dilutional effect on sodium levels can be reduced, aiding in a safer and more controlled correction of hyponatremia without causing fluid overload. Administering sodium can lead to rapid changes in sodium levels, increasing the risk of complications.
Recommendations for hepatitis B (HBV) vaccine include which statement?
- A. First dose is given between birth and age 2 days.
- B. First dose is given between ages 12 and 15 months.
- C. It is not recommended for neonates who are at low risk for hepatitis B.
- D. It is not recommended for neonates whose mothers are positive for HBV surface antigen.
Correct Answer: B
Rationale: The current recommendations for hepatitis B (HBV) vaccine state that the first dose should be administered between ages 12 and 15 months. The vaccine series typically consists of three doses, with the second dose administered 1-2 months after the first dose, and the third dose given at least 8 weeks after the second dose. This schedule is recommended by the Centers for Disease Control and Prevention (CDC) to provide optimal protection against the hepatitis B virus. Starting the vaccine series at 12-15 months ensures that the child's immune system is mature enough to respond effectively to the vaccine and generate lasting immunity.
A patient who is recovering from a stroke becomes easily frustrated when unable to complete a task. Which of the ff. responses by the nurse will best help the patient get the task done?
- A. Perform the task for the patient
- B. Tell the patient not to worry about it
- C. Break the task down into simple steps
- D. Have another patient demonstrate how to perform the task
Correct Answer: C
Rationale: Breaking the task down into simple steps is the best response by the nurse to help the patient get the task done. By breaking the task into smaller, more manageable steps, the patient can focus on completing each step successfully, leading to a sense of accomplishment and reducing frustration. This approach promotes a positive and empowering experience for the patient, ultimately aiding in their recovery and rehabilitation process.