Nokea
Place the steps for removal of a foreign body from the ear canal in the correct order.
- A. Refer for treatment of external otitis.
- B. Inspect the tympanic membrane for trauma.
- C. Obtain history for type of object.
- D. Choose appropriate fluid for irrigation or instillation.
Correct Answer: C
Rationale: Obtaining a history helps determine the safest method for removing the foreign body and prevents further injury.
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What is one reason that might apply to a client’s rationale for using alternative therapy?
- A. Desire to become more active in decision-making and self-care.
- B. Chronic incurable back condition.
- C. Difficulty meeting the rising costs of healthcare.
- D. Client does not share traditional American health beliefs and practices.
Correct Answer: A
Rationale: Clients often seek alternative therapies to take a more active role in their healthcare decisions and self-management.
What is the term used for assessment data that the patient tells you about?
- A. Focused
- B. Objective
- C. Subjective
- D. Comprehensive
Correct Answer: C
Rationale: The correct answer is 'Subjective.' Subjective data includes patient-reported symptoms, feelings, and experiences.
Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is
- A. vital signs.
- B. surgical site.
- C. respiratory adequacy.
- D. level of consciousness.
Correct Answer: C
Rationale: Respiratory adequacy is critical immediately postoperatively to ensure oxygenation and ventilation.
How does the pain of a myocardial infarction (MI) differ from stable angina?
- A. Accompanied by shortness of breath
- B. Feelings of fear or anxiety
- C. Lasts less than 15 minutes
- D. No relief from taking nitroglycerin
Correct Answer: C
Rationale: The correct answer is C because the pain of a myocardial infarction (MI) typically lasts longer than 15 minutes, unlike stable angina which lasts for a shorter duration. MI pain is usually described as intense, crushing, and prolonged, whereas stable angina pain is often triggered by exertion and relieved by rest or medication like nitroglycerin. Choices A, B, and D are incorrect because shortness of breath, feelings of fear or anxiety, and lack of relief from nitroglycerin are not definitive differentiating factors between MI and stable angina.
A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?
- A. Breathing so rapidly interferes with oxygenation.
- B. Maybe the client has respiratory distress syndrome.
- C. The blood clot interferes with perfusion in the lungs.
- D. The client needs immediate intubation & mechanical ventilation.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. A pulmonary embolism is a blockage in one of the pulmonary arteries, affecting blood flow to the lungs.
2. This blockage limits perfusion, the process of blood flow through the lungs for oxygenation.
3. Oxygen saturation may not improve significantly because the blood clot interferes with perfusion, not ventilation.
4. Options A and B focus on ventilation issues, which may not be the primary concern in this case.
5. Option D is extreme and not supported by the information given about the client's condition.
Summary:
Choice C is correct because a pulmonary embolism affects perfusion in the lungs, leading to decreased oxygen saturation. Choices A, B, and D are incorrect as they focus on other issues not directly related to the client's condition.