Nokea
During the rehabilitation of a patient with limited mobility, how can decubitus ulcers be prevented?
- A. Turning the patient every 4 hours
- B. Using a heat lamp on reddened areas
- C. Applying vitamin C to bony prominences
- D. Keeping the skin clean, dry, and well lubricated
Correct Answer: D
Rationale: Maintaining skin integrity through cleanliness and moisture management prevents pressure ulcers.
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Patient teaching for risk reduction of skin cancer should include
- A. Having suspicious moles checked by a dermatologist.
- B. Daily sun exposure every 1/2 hour.
- C. Daily sun exposure of 1 hour to build tolerance.
- D. Applying moisturizer.
Correct Answer: A
Rationale: Regular monitoring of moles and avoiding excessive sun exposure are vital for skin cancer prevention.
When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?
- A. Movement of the trachea toward the unaffected side
- B. Bubbling of the water in the water seal chamber with exhalation
- C. Crepitus in the area above and surrounding the insertion site
- D. Eyelets not visible
Correct Answer: A
Rationale: Step 1: Movement of the trachea toward the unaffected side indicates tension pneumothorax, a life-threatening condition requiring immediate intervention.
Step 2: This finding can lead to compromised breathing and hemodynamic instability if not addressed promptly.
Step 3: B: Bubbling in the water seal chamber with exhalation is expected in a properly functioning chest tube system.
Step 4: C: Crepitus at the insertion site is common due to air entering subcutaneous tissue during tube placement and is not an urgent concern.
Step 5: D: Eyelets not visible can indicate dislodgement but is not as critical as tracheal deviation in this scenario.
A 35-year-old client is admitted for elective tubal ligation. During the preoperative teaching, the client states, 'The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?' The best explanation by the nurse is that balanced anesthesia:
- A. is a type of regional anesthesia.
- B. uses equal amounts of inhalation agents and liquid agents.
- C. does not depress the central nervous system.
- D. is a combination of several anesthetic agents or drugs, which produce a smooth induction with minimal complications.
Correct Answer: D
Rationale: A regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. Varying amounts of anesthetic agents are used when employing balanced anesthesia. The amounts used depend on the age, weight, condition of the client and the surgical procedure. General anesthesia is a drug induced depression of the central nervous system, which produces loss of consciousness and decreased muscle activity. Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.
The first priority to care for the patient with a new fracture includes assessing
- A. Respiratory rate and effort, as well as pulse.
- B. The fracture site for bleeding.
- C. For signs of infection at the wound site of an open fracture.
- D. For circulation and sensation distal to the fracture site.
Correct Answer: D
Rationale: Assessing circulation and sensation ensures no compromise to distal structures.
Tom has Guillain-Barré syndrome and asks what causes his burning, prickling feeling. You respond by saying
- A. You are lying too long on the affected side.
- B. This is in response to your medication.
- C. The myelin cover of the nerve endings is absent.
- D. This is secondary to dysphagia.
Correct Answer: C
Rationale: Guillain-Barré syndrome damages the myelin sheath, leading to abnormal sensations.