Nokea
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
- A. Massage reddened areas with lotion or oils
- B. Use special water mattress
- C. Turn frequently every 2 hours
- D. Keep skin clean and dry
Correct Answer: C
Rationale: The correct answer is C: Turn frequently every 2 hours. This helps redistribute pressure, preventing constant pressure on one area and reducing the risk of developing pressure ulcers. Turning every 2 hours promotes circulation and relieves pressure points.
A: Massaging reddened areas can worsen the condition by increasing friction and pressure.
B: While a special water mattress can help in preventing pressure ulcers, turning frequently is more effective.
D: Keeping the skin clean and dry is important for overall skin health but may not directly prevent pressure ulcers.
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Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. Administer 2 to 3L of IV fluid rapidly
- B. Administer 6L of IV fluid over the first 24 hours
- C. Administer a dextrose solution containing normal saline solution
- D. Administer IV fluid slowly to prevent circulatory overload and collapse
Correct Answer: B
Rationale: The correct answer is B: Administer 6L of IV fluid over the first 24 hours. In HHNS, dehydration is severe due to high blood glucose levels causing osmotic diuresis. Rapid infusion of fluid can lead to fluid overload and exacerbate the situation. Administering 6L over 24 hours helps gradually replenish lost fluids without causing circulatory overload. Choice A is incorrect because rapid infusion can lead to fluid overload. Choice C is incorrect because adding dextrose to the solution can further increase blood glucose levels. Choice D is incorrect because administering IV fluids slowly can delay rehydration in a critical situation like HHNS.
Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
- A. Hyperventilating James with 100% oxygen before and after suctioning
- B. Instilling 3 to 5 ml normal saline to loosen up secretion
- C. Applying suction during catheter withdrawal
- D. Suction the client every hour
Correct Answer: A
Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows:
1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity.
2. Oxygen toxicity can result in lung damage and other complications.
3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations.
Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.
Which of the following types of cells is the immune system’s shutoff mechanism?
- A. Plasma cells
- B. Suppressor T cells
- C. Helper T cells
- D. B lymphocytes
Correct Answer: B
Rationale: The correct answer is B: Suppressor T cells. Suppressor T cells regulate the immune response by inhibiting the activity of other immune cells to prevent overreaction and maintain immune balance. They play a crucial role in preventing autoimmune diseases and excessive inflammation. Plasma cells (A) produce antibodies, Helper T cells (C) assist in activating other immune cells, and B lymphocytes (D) are involved in antibody production. Suppressor T cells specifically have the function of shutting down immune responses, making them the immune system’s shutoff mechanism.
The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
- A. Sodium level of 140 mEq/l.
- B. Direct bilirubin level of 2 mg/dl
- C. Prothrombin time of 12 seconds
- D. Platelet count of 400,000/mm3
Correct Answer: B
Rationale: The correct answer is B: Direct bilirubin level of 2 mg/dl. Acetaminophen toxicity can lead to liver damage, causing an increase in bilirubin levels. Direct bilirubin specifically indicates liver function. A: Sodium level is not related to acetaminophen toxicity. C: Prothrombin time is a measure of blood clotting, not indicative of acetaminophen toxicity. D: Platelet count is not affected by acetaminophen toxicity.
A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
- A. The client’s diet
- B. The client’s family member’s history of
- C. The client’s drug history chronic diseases
- D. The client’s ability to produce antibodies
Correct Answer: D
Rationale: The correct answer is D: The client's ability to produce antibodies. This is crucial in assessing immune system disorders as antibodies play a key role in fighting infections and other foreign invaders. By evaluating the client's ability to produce antibodies, the nurse can determine if the immune system is functioning properly.
A: The client's diet is not directly related to immune system disorders unless there are specific deficiencies impacting immune function.
B: The client's family member's history of chronic diseases may provide some genetic predisposition information but does not directly assess the client's immune system.
C: The client's drug history is important but more relevant to medication interactions and side effects rather than evaluating the immune system.