Nokea
Mary, who is diagnosed with osteomyelitis, may not heal properly unless she has
- A. Debridement and drainage of the area.
- B. Immobilization of the area.
- C. Ice packs alternating with moist heat, applied externally.
- D. Internal fixation device inserted.
Correct Answer: A
Rationale: Debridement and drainage are necessary to remove infected tissue and promote healing.
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A client presents with shortness of breath, pain in the lung area, and a recent history of starting birth control pills and smoking. Vital signs include a heart rate of 110/min, respiratory rate of 40/min, and blood pressure of 140/80 mm Hg. Arterial blood gases reveal pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. What is the priority nursing intervention?
- A. Prepare for mechanical ventilation.
- B. Administer oxygen via face mask.
- C. Prepare to administer a sedative.
- D. Assess for indications of pulmonary embolism.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen via face mask. Given the client's symptoms and ABG results showing respiratory alkalosis and hypoxemia, the priority is to improve oxygenation. Administering oxygen via face mask will help increase the oxygenation levels and alleviate the hypoxemia. Mechanical ventilation (A) is not indicated as the client is able to maintain their own ventilation. Administering a sedative (C) is not appropriate without addressing the underlying respiratory issue. Assessing for pulmonary embolism (D) may be important but not the immediate priority in this case.
A client with chronic obstructive pulmonary disease is being taught by a nurse about ways to facilitate eating. Which of the following statements indicates a need for further teaching?
- A. I will rest for at least 30 minutes before eating.
- B. I will take my bronchodilators after meals.
- C. I will eat five or six small meals each day.
- D. I will choose foods that are not gas-forming.
Correct Answer: B
Rationale: The correct answer is B: "I will take my bronchodilators after meals." Taking bronchodilators after meals can decrease their effectiveness due to delayed absorption. Step 1: Bronchodilators should be taken before meals to open airways for better breathing. Step 2: Resting before meals (A) can reduce shortness of breath. Eating small meals (C) can prevent overeating and aid digestion. Choosing non-gas forming foods (D) can reduce bloating.
In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?
- A. Airway protection
- B. Decreasing intracranial pressure
- C. Stabilizing cardiac arrhythmias
- D. Preventing musculoskeletal disability
Correct Answer: A
Rationale: The correct answer is A: Airway protection. The priority focus of care in a client with multiple system trauma is to ensure a patent airway to maintain oxygenation and ventilation. Without a clear airway, the client can rapidly deteriorate. Airway management takes precedence over other interventions to prevent hypoxia and respiratory failure. Decreasing intracranial pressure (B) and stabilizing cardiac arrhythmias (C) are important but secondary to ensuring adequate oxygenation. Preventing musculoskeletal disability (D) is not the immediate concern in this critical situation.
Anne asks how a chest x-ray would help the physician examine her heart. You respond by saying
- A. A chest x-ray is used to rule out that a fractured rib caused your pain.
- B. The chest x-ray is an error. I will cancel the order.
- C. A chest x-ray is used to detect the size and position of the heart.
- D. All patients who are admitted must have a chest x-ray.
Correct Answer: C
Rationale: Chest x-rays provide information about heart size and position.
What cell ingests invading or foreign cells?
- A. Macrophage.
- B. T cell.
- C. B cell.
- D. Erythrocyte.
Correct Answer: A
Rationale: Macrophages engulf and destroy pathogens.