Nokea
Match the phases of the nursing process with the descriptions (phases may be used more than once).
- A. None
- B. Analysis of data
- C. Priority setting
- D. Nursing interventions
Correct Answer: B
Rationale: Analysis of data corresponds to the Diagnosis phase, where health problems are identified based on assessed data.
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Identify the options for communication with each type of client: A client who has suffered a stroke, has expressive aphasia, and has lost use of their dominant hand.
- A. Use written communication and visual aids.
- B. Ask a family member to interpret.
- C. Speak louder and slower.
- D. Use sign language.
Correct Answer: A
Rationale: Written communication and visual aids help bridge the gap caused by expressive aphasia and physical limitations.
A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?
- A. Administer an IV fluid bolus.
- B. Check the surgical site for bleeding.
- C. Place the client in a Trendelenburg position.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Check the surgical site for bleeding. This is the first action the nurse should take as a sudden drop in blood pressure postoperatively could indicate internal bleeding, a common complication after abdominal surgery. By assessing the surgical site for bleeding, the nurse can identify and address the source of the hypotension promptly. Administering IV fluids (choice A) may be necessary but should come after determining the cause. Placing the client in Trendelenburg position (choice C) is not recommended as it can worsen venous return and increase intracranial pressure. Notifying the healthcare provider (choice D) should be done after the nurse has assessed the situation and taken immediate action.
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
- A. Complete set of vital signs
- B. Palpation and auscultation of the abdomen
- C. Brief neurologic assessment
- D. Initiation of pulse oximetry
Correct Answer: C
Rationale: A brief neurologic assessment helps quickly identify potential brain injuries or other neurological deficits.
What correctly describes pursed-lip breathing?
- A. Breathe in to count of 4 and out to count of 2, pursing lips
- B. Breathe in through nose and slowly exhale through pursed lips
- C. Place one hand on abdomen and other on chest, inhaling through pursed lips and exerting pressure on inspiration
- D. Take in a deep breath, through pursed lips, then let out one-third; continue this pattern
Correct Answer: B
Rationale: Pursed-lip breathing involves slow exhalation to prolong expiration and improve airflow.
Place the events below in the order they occur in the patient with obstructive sleep apnea (beginning with 1).
- A. Sleep just before going to work
- B. Narrowing of air passages with muscle relaxation during sleep
- C. Apnea lasting 10 to 90 seconds
- D. Brief arousal and airway opened
Correct Answer: C
Rationale: The correct order is E (narrowing), A (apnea), C (arousal). Muscle relaxation leads to airway narrowing, followed by apnea and then arousal.