Nokea
During a Romberg test, the patient is asked to assume which position?
- A. Sitting
- B. Standing
- C. Genupectoral
- D. Trendelenburg
Correct Answer: B
Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.
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All of the following interventions are correct when using the Z-track method of drug injection except:
- A. Prepare the injection site with alcohol
- B. Use a needle that is at least 1" long
- C. Aspirate for blood before injection
- D. Rub the site vigorously after the injection to promote absorption
Correct Answer: D
Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1" long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.
Which of the following principles of primary nursing has proven most satisfying to the patient and nurse?
- A. Continuity of patient care promotes efficient and cost-effective nursing care.
- B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
- C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
- D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.
Correct Answer: D
Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.
In Maslow's hierarchy of physiological needs, the human need of greatest priority is:
- A. Love
- B. Elimination
- C. Nutrition
- D. Oxygen
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When removing a contaminated gown, what should be the first thing touched by the nurse?
- A. Waist tie and neck tie at the back of the gown
- B. Waist tie in front of the gown
- C. Cuffs of the gown
- D. Inside of the gown
Correct Answer: A
Rationale: When removing a contaminated gown, the nurse should ensure the first thing touched is the waist tie and neck tie at the back of the gown. This procedure helps prevent contamination by ensuring that the outer surface of the gown, which is likely to be contaminated, is not touched during removal. By touching the back ties first, the nurse minimizes the risk of transferring any contaminants to themselves or the environment.
What is the appropriate needle size for insulin injection?
- A. 18G, 1 ½" long
- B. 22G, 1" long
- C. 22G, 1 ½" long
- D. 25G, 5/8" long
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.