Nokea
Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects the ability of chance activity for an otherwise healthy older adult?
- A. Drinks 1,500 mL of fluids per day.
- B. Consumes a balanced diet of 1,200 calories per day.
- C. Walks briskly for 10 minutes three times per week.
- D. Sleeps at least 8 hours each night.
Correct Answer: C
Rationale: Brisk walking promotes cardiovascular health and mobility. 1,500 mL fluid may be insufficient, 1,200 calories is too low for most, and 8 hours sleep is not activity-focused.
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When completing the Preoperative Checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?
- A. Administer the prescribed pre-anesthetic medication.
- B. Note this new allergy prominently at the front of the chart.
- C. Contact the scrub nurse in the operating room.
- D. Inform the nurse anesthetist.
Correct Answer: D
Rationale: A newly discovered allergy must be communicated to the nurse anesthetist first, as it may affect anesthesia choices and prevent allergic reactions during surgery.
When the nurse administers I.V. midazolam hydrochloride (Versed), the client demonstrates signs of an overdose. The nurse should next collaborate with the surgical team to:
- A. Ventilate with an oxygenated Ambu bag.
- B. Shock the client with ECG paddles.
- C. Administer 0.5 mL 1:1000 epinephrine.
- D. Titrate flumazenil (Romazicon).
Correct Answer: D
Rationale: Flumazenil is the specific reversal agent for benzodiazepine overdose, such as with midazolam. Titrating flumazenil reverses sedation and respiratory depression effectively.
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they appear to help:
- A. Encourage formation of tough skin.
- B. Promote the growth of epithelial tissue.
- C. Provide for permanent wound closure.
- D. Facilitate development of subcutaneous tissue.
Correct Answer: B
Rationale: Porcine grafts act as a temporary biological dressing, promoting epithelial tissue growth by providing a protective barrier and stimulating healing. They do not form tough skin, provide permanent closure, or directly affect subcutaneous tissue.
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
- A. Institute range-of-motion (ROM) exercise every 4 hours.
- B. Massage the abdomen once a shift.
- C. Use an alternating air pressure mattress.
- D. Elevate the lower extremities.
Correct Answer: C
Rationale: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema and ascites. ROM exercises (A) and elevation (D) are supportive but secondary. Abdominal massage (B) is not indicated.
Which client position is contraindicated for a client with a spinal cord injury?
- A. Supine with head flat.
- B. Logrolling technique.
- C. Head elevated 30 degrees.
- D. Neutral neck alignment.
Correct Answer: A
Rationale: Supine with head flat is contraindicated as it may increase spinal pressure; other positions support alignment and safety.