Nokea
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches.
- B. Green drainage.
- C. Reddened tissue.
- D. Eschar development.
Correct Answer: C
Rationale: Reddened tissue indicates healthy granulation tissue.
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A client with a tracheostomy is being cared for by a nurse. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
- A. Attending a class on tracheostomy care
- B. Verbally explaining all steps in the procedure
- C. Performing the procedure independently
- D. Asking relevant questions about suctioning
Correct Answer: C
Rationale: The correct answer is C: Performing the procedure independently. This indicates readiness for discharge as it demonstrates the partner's ability to safely and effectively perform suctioning without direct supervision. Attending a class (A) and asking relevant questions (D) are important but do not necessarily indicate competence in performing the procedure. Verbally explaining the steps (B) shows understanding but does not confirm practical skill.
When admitting a client with active tuberculosis to a room on a medical-surgical unit, which of the following room assignments should the nurse make?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with another nonsurgical client
- C. A room in the ICU
- D. A room that is within view of the nurses' station
Correct Answer: A
Rationale: The correct answer is A: a room with air exhaust directly to the outdoor environment. This is to prevent the spread of tuberculosis to other patients and healthcare workers. Tuberculosis is an airborne disease, so proper ventilation is crucial. Choice B is incorrect as placing the client with another nonsurgical client may increase the risk of transmission. Choice C is not ideal as the ICU may have other vulnerable patients. Choice D is also incorrect as the proximity to the nurses' station does not address the need for proper ventilation to prevent the spread of tuberculosis.
In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
- A. Natural death acts
- B. Allow natural death
- C. Advance care planning
- D. Do Not Resuscitate order.
Correct Answer: C
Rationale: Advance care planning encompasses various legal documents that outline a person's healthcare preferences and appoints proxies to make decisions on their behalf when incapacitated.
Tom arrives in the Emergency Room (ER) and is unable to move his legs as a result of an automobile accident that occurred 30 minutes ago. You respond by saying
- A. Swelling due to the initial trauma prevents you from moving your legs.
- B. There are good rehabilitation centers that will help restore sensation to your legs.
- C. Swelling due to the initial trauma may make the injury seem more severe than it actually is. A more accurate assessment will be made once the swelling goes down.
- D. You should have been wearing your seatbelt.
Correct Answer: C
Rationale: Initial swelling can mask the true extent of spinal injuries.
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly
apneic episodes. Which of the following client statements indicates an understanding of the teaching?
- A. "It might help if I tried sleeping only on my back."
- B. "I'll sleep better if I take a sleeping pill at night."
- C. "I'll get a humidifier to run at my bedside at night."
- D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Correct Answer: D
Rationale: The correct answer is D because losing weight can help reduce the severity and frequency of obstructive sleep apnea. Excess weight can lead to fat deposits around the upper airway, causing obstruction during sleep. By losing weight, the airway may become less obstructed, reducing apneic episodes.
Choice A is incorrect because sleeping on the back can actually worsen sleep apnea by causing the tongue and soft tissues to block the airway.
Choice B is incorrect because sleeping pills can relax the muscles in the airway, making it more likely for an individual with sleep apnea to experience episodes of apnea.
Choice C is incorrect because while a humidifier can alleviate some symptoms like dryness, it does not directly address the underlying cause of obstructive sleep apnea related to obesity.