Nokea
Elderly patients are more prone to dehydration than younger people because the elderly ___________.
- A. drink more coffee and tea
- B. have more stomach mucus production
- C. have more saliva
- D. have less sense of thirst
Correct Answer: D
Rationale: Elderly patients are prone to dehydration because they have a lower and diminished sense of thirst. This reduced sensation of thirst makes them less likely to drink an adequate amount of fluids, leading to dehydration. While it is true that elderly individuals may also have changes such as decreased stomach mucus production and saliva production, these factors do not directly contribute to dehydration. Drinking more coffee and tea, as mentioned in choice A, is not a consistent behavior among all elderly individuals and is not a primary reason for their increased risk of dehydration.
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When escorting a patient to the operating room on a stretcher, what should you do to prevent the patient from falling?
- A. Ensure the safety belt or strap is secured on the patient while escorting them to the operating room
- B. Use a safety belt or strap on the patient throughout their escort to the operating room
- C. Lower the bed position when moving the patient from the bed to the stretcher
- D. All of the above options are correct
Correct Answer: B
Rationale: When escorting a patient to the operating room on a stretcher, it is crucial to secure a safety belt or strap on the patient to prevent falls during the transfer. This safety measure is not considered a restraint but a necessary precaution. Lowering the bed position is not necessary; in fact, the bed should be in a high position to align with the stretcher. Locking the wheels of the stretcher is essential to prevent accidents during patient transfer. Therefore, the correct action to prevent falls while moving a patient to the operating room is to use a safety belt or strap on the patient throughout the escort.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
- A. I will avoid being outdoors whenever possible.
- B. My husband will be sleeping in the guest bedroom.
- C. I will take the bus instead of driving to visit my friends.
- D. I will keep the windows closed at home to contain the germs.
Correct Answer: B
Rationale: To prevent the transmission of pulmonary tuberculosis, it is important for the infected individual to minimize exposure to close contacts and household members. Sleeping alone in a separate room, like the guest bedroom, is an effective measure. The other choices are not ideal: Choice A is incorrect because spending time outdoors is encouraged for ventilation; Choice C is incorrect as using public transportation increases the risk of transmission; Choice D is incorrect because keeping windows closed limits ventilation, which is necessary to reduce the concentration of infectious particles in the air.
Which of the following is a local sign of infection?
- A. Swelling
- B. Rapid pulse
- C. Fever
- D. High white blood count
Correct Answer: A
Rationale: A local sign of infection refers to symptoms that are specific to the area of infection. Swelling, heat, pain, and redness near the infected site are examples of local signs. In the context of infection, swelling occurs due to an accumulation of fluid and immune cells at the site of infection. Rapid pulse, fever, and high white blood count are more systemic responses to infection and not specific local signs. Rapid pulse can indicate systemic distress or sepsis, fever is a systemic response to infection, and high white blood count is a laboratory finding that suggests an immune response but is not a direct sign of infection at a specific site.
Tommy R., your 68-year-old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy's ______________ in order to prevent him from falling again.
- A. bedside rails up at all times
- B. bed in the low position
- C. call bell within reach
- D. family members in the room at all times
Correct Answer: C
Rationale: To prevent falls, it is essential to keep the patient's call bell within reach so they can easily call for help when needed. This allows for timely assistance and can prevent falls. While low beds can reduce the severity of injuries in case of a fall, they do not prevent falls from happening. Having family members in the room at all times is not a realistic or practical solution. Side rails can actually increase the severity of falls as patients may attempt to climb over them, and using side rails as fall prevention is considered a restraint practice that can lead to entrapment and other risks.
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam?
- A. Start the hepatitis B immunization series.
- B. Teach the patient about hepatitis A immune globulin.
- C. Ask whether the patient has been screened for hepatitis C.
- D. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
Correct Answer: C
Rationale: The correct action for the nurse to include in care when the patient is seen for a routine annual physical exam, according to CDC guidelines, is to ask whether the patient has been screened for hepatitis C. CDC guidelines recommend screening patients born between 1945 and 1965 for hepatitis C due to the high prevalence of undiagnosed cases in this age group. Starting the hepatitis B immunization series is not necessary as the patient already had hepatitis A infection. Teaching the patient about hepatitis A immune globulin is not indicated in this scenario. Testing for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM) is not needed as the patient has already had hepatitis A.