Nokea
Damage to the VII cranial nerve results in:
- A. Facial pain
- B. Absence of ability to smell
- C. Absence of eye movement
- D. Tinnitus
Correct Answer: C
Rationale: The VII cranial nerve (facial nerve) controls facial muscles; damage causes facial paralysis, affecting eye movement (e.g., inability to close the eye).
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The client who is admitted with thrombophlebitis has an order for heparin. The medication should be administered using a/an:
- A. Buretrol
- B. Infusion controller
- C. Intravenous filter
- D. Three-way stop-cock
Correct Answer: B
Rationale: An infusion controller ensures precise heparin delivery, critical for maintaining therapeutic levels and preventing complications.
A client on the post-op floor underwent surgery 4 days ago. The night nurse reports to the nurse coming on to dayshift that the client complained all night of pain, even though she received every dose of prescribed pain medication. The client currently rates the pain at a 10 out of 10. The day shift nurse should first
- A. call the physician and ask her to prescribe a different medication.
- B. work with the client on alternative pain relief measures such as guided imagery.
- C. administer the next dose of pain medication, but observe the client swallow it to ensure she is really taking the medication.
- D. complete a full head-to-toe assessment on the client.
Correct Answer: D
Rationale: Persistent severe pain post-op suggests a complication (e.g., infection, hemorrhage). A full assessment is the priority to identify the cause before adjusting treatment.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A. A client with AIDS being treated with Foscarnet
- B. A client with a fractured femur in a long leg cast
- C. A client with laryngeal cancer with a laryngectomy
- D. A client with diabetic ulcers to the left foot
Correct Answer: A
Rationale: Foscarnet requires monitoring for toxicity, making this client a priority.
A 65-year-old client is admitted after a stroke. The nurse is concerned about skin breakdown and decubitus ulcer development. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning the client promotes blood circulation, which enhances tissue perfusion and prevents pressure ulcers. Assessing the skin detects problems but doesn't improve perfusion, massaging erythematous areas can worsen tissue damage, and changing pads addresses hygiene but not perfusion directly.
Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?
- A. Antivirals
- B. Antibiotics
- C. Immunosuppressants
- D. Analgesics
Correct Answer: C
Rationale: Immunosuppressants, such as cyclosporine, prevent the immune system from forming antibodies against the transplanted heart.