Nokea
How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Restraints must be released every 2 hours to assess circulation, skin integrity, and client comfort, with assessments every 30 minutes while restrained.
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A community health nurse is asked to organize a health promotion project that plans to provide glucose screening. This activity is most beneficial within what realm?
- A. Testing that is performed by volunteers at a local department store and is open to the public
- B. At a professional health fair activity available for selected persons who have been screened as being at risk
- C. Mass-marketing vouchers for free fingersticks at a local drug store, where the pharmacist makes recommendations on the findings
- D. Testing that is performed by a nurse professional, who immediately provides education regarding the findings
Correct Answer: B
Rationale: Glucose screening is most effective for high-risk or symptomatic individuals at a health fair, ensuring targeted and meaningful results.
Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord?
- A. Brown-Séquard syndrome
- B. posterior cord syndrome
- C. central cord syndrome
- D. cauda equina syndrome
Correct Answer: A
Rationale: Brown-Séquard syndrome is a result of damage to one-half of the spinal cord. The other choices are also incomplete lesions of the spinal cord, but they have different defining characteristics.
Which of the following conditions has a severe complication of respiratory failure?
- A. Bell's palsy
- B. Guillain-Barré syndrome
- C. Trigeminal neuralgia
- D. Tetanus
Correct Answer: B
Rationale: Guillain-Barré syndrome can lead to respiratory failure due to progressive muscle weakness affecting respiratory muscles, unlike the other conditions.
The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?
- A. performing a physical assessment prior to administration
- B. obtaining the most recent lab values regarding renal function
- C. reviewing peaks and troughs for the past few days
- D. ensuring the client is not allergic to the medication
Correct Answer: D
Rationale: Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.
Which isolation procedure will be followed for secretions and blood?
- A. Respiratory
- B. Standard Precautions
- C. Contact Isolation
- D. Droplet
Correct Answer: B
Rationale: Standard precautions are taken in all situations for all clients and involve all body secretions except sweat and are designed to reduce the rate of transmission of microbes from one host to another or one source (environment such as the client's bedside table) to another.