Nokea
Mr. Johnstone is treated for removal of foreign bodies in both eyes and is discharged with patches on both eyes. In teaching Mr. Johnstone's family to assist him in walking, the nurse advises the family member to
- A. grasp him by the arm and walk behind him
- B. grasp him by the arm and walk in front of him
- C. offer your arm and walk in front of him
- D. offer your arm and walk behind him
Correct Answer: C
Rationale: Offering an arm and walking slightly ahead provides guidance and support while allowing the visually impaired person to follow safely.
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Which actions are done primarily by an informatics nurse (select all that apply)?
- A. Designs and builds computer systems
- B. Studies the validity of nursing information
- C. Trains health care providers to provide nursing care
- D. Communicates and accesses information for nursing staff
Correct Answer: A
Rationale: Informatics nurses focus on designing systems, validating information, and building tools to support nursing processes.
Build-up of bile salts may cause the systemic symptom of
- A. Hypotension.
- B. Pruritis (itching).
- C. Ecchymosis (bruising).
- D. Urticaria (hives).
Correct Answer: B
Rationale: Bile salt accumulation can lead to itching.
What should be included in Mr. Ross’s plan of care during radiation therapy if he complains of weakness and lethargy?
- A. Encouraging him to rest more than usual
- B. Monitoring his intake and output
- C. Helping him to accept his condition
- D. Checking his blood pressure daily
Correct Answer: A
Rationale: Rest conserves energy and aids recovery during radiation therapy.
In planning Mrs. Filbert's care during an acute attack of Meniere disease, it would be most important to
- A. encourage her to discuss her feelings about her illness
- B. keep her siderails up and provide assistance when she is permitted out of bed
- C. instruct her about prescribed dietary modifications
- D. encourage her to walk around her room so that her joints will not get stiff
Correct Answer: C
Rationale: Dietary changes, such as reducing salt intake, play a key role in managing Meniere disease by helping control fluid balance in the inner ear.
How should the nurse position Mr. Jones’ chest drainage unit while he is transported?
- A. Below the chest level
- B. On the stretcher
- C. The unit should be removed
- D. The tubes should be clamped
Correct Answer: A
Rationale: The correct answer is A: Below the chest level. Positioning the chest drainage unit below the chest level allows for effective drainage of air or fluid from the chest cavity. Placing it above the chest level may cause backflow or air/fluid accumulation. Option B is incorrect as the unit should be secured to prevent dislodging during transport. Option C is incorrect as removing the unit can lead to complications. Option D is incorrect as clamping the tubes can result in a tension pneumothorax. Positioning the unit below the chest level ensures proper drainage and prevents complications during transport.