Nokea
For a rectal examination, the patient can be directed to assume which of the following positions?
- A. Genupectoral
- B. Sims
- C. Horizontal recumbent
- D. All of the above
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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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.
Which of the following measures is not recommended to prevent pressure ulcers?
- A. Massaging the reddened area with lotion
- B. Using a water or air mattress
- C. Adhering to a schedule for positioning and turning
- D. Providing meticulous skin care
Correct Answer: A
Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.
A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct Answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
What is the most common injury among elderly persons?
- A. Atherosclerotic changes in the blood vessels
- B. Increased incidence of gallbladder disease
- C. Urinary Tract Infection
- D. Hip fracture
Correct Answer: D
Rationale: Hip fracture is the most common injury among elderly persons. As people age, their bones become more fragile, making them more susceptible to hip fractures, often resulting from falls. These fractures can significantly impact an elderly person's quality of life and mobility, making them a significant concern in geriatric care.
A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?
- A. Complain to her fellow nurses
- B. Wait until she knows more about the unit
- C. Discuss the problem with her supervisor
- D. Inform the staff that they must volunteer to rotate
Correct Answer: C
Rationale: In this scenario, the new head nurse should discuss the problem with her supervisor. This is the most appropriate action as the supervisor is in a position to address staffing concerns effectively and make necessary changes. Complaining to fellow nurses may not lead to a solution, waiting may exacerbate the issue, and demanding staff rotation without proper discussion is not a collaborative approach to resolving the problem.