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: The correct answer is D (Downward) because it helps to maintain a clear airway for effective mouth-to-mouth respiration. By holding the victim's chin downward, you can ensure proper alignment of the airway, allowing the tongue to fall forward and prevent obstruction. Holding the chin forward (Choice A) may cause the airway to close, holding it backward (Choice B) may strain the neck, and holding it sideward (Choice C) may not provide optimal airway alignment. Holding the chin downward is the most effective and safe method for providing mouth-to-mouth respiration.
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Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?
- A. Do not leave the patient unattended at any time.
- B. Teach the patient not to bend over.
- C. Report sudden onset of acute pain.
- D. Apply sandbags to either side of the head.
Correct Answer: C
Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications.
A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain.
B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain.
D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.
Which of the following is an example of a well-stated nursing intervention?
- A. Client will drink 100 mL of water every 2 hours while awake.
- B. Offer client 100 mL of water every 2 hours while awake.
- C. Offer client water when he complains of thirst.
- D. Client will continue to increase oral intake when awake.
Correct Answer: B
Rationale: The correct answer is B because it provides a specific action (offering water) at regular intervals (every 2 hours) to promote hydration, which is a clear and measurable nursing intervention. Choice A is too prescriptive and lacks flexibility. Choice C is reactive and not proactive. Choice D is vague and lacks specific guidance on how to achieve the desired outcome. By offering water consistently, the nurse ensures proactive care and helps meet the client's hydration needs effectively.
Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
- A. Low fowler’s
- B. Modified trendelenburg
- C. Side lying
- D. Supine NERVOUS SYSTEM
Correct Answer: C
Rationale: The correct answer is C: Side lying position. This position helps prevent aspiration of secretions and promotes drainage from the mouth during and after a seizure. Placing the patient in a side lying position also helps prevent injury from falling and facilitates monitoring of the patient's airway.
Incorrect choices:
A: Low fowler's - This position does not provide optimal airway protection and may increase the risk of aspiration during a seizure.
B: Modified trendelenburg - This position may worsen the patient's airway patency and does not facilitate drainage of secretions.
D: Supine - Placing the patient in a supine position can lead to aspiration and compromise the airway, especially during a seizure.
Summary: The side lying position is the most appropriate choice as it ensures airway protection, facilitates drainage, and reduces the risk of aspiration during and after a seizure.
Which of the following tests would the nurse use as an initial screening test to determine hearing loss?
- A. Romberg test
- B. Caloric test
- C. Otoscopic examination
- D. Whisper voice test
Correct Answer: D
Rationale: The correct answer is D: Whisper voice test. This test is used as an initial screening for hearing loss because it is simple, quick, and easily administered by a nurse. The nurse would whisper words or numbers at a specific distance from the patient to assess their ability to hear and repeat the whispered sounds accurately. This test provides a quick indication of potential hearing impairment.
The other choices are incorrect:
A: Romberg test assesses balance and not hearing.
B: Caloric test evaluates the vestibular system, not hearing.
C: Otoscopic examination is used to examine the ear canal and tympanic membrane, not to screen for hearing loss.
In an individual with Sjogren’s syndrome, nursing care should focus on:
- A. Moisture replacement
- B. Nutritional supplementation
- C. Electrolyte balance
- D. Arrhythmia management
Correct Answer: A
Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (C) and arrhythmia management (D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.