Nokea
Prior to a thoracentesis, what intervention should the nurse complete?
- A. Measure oxygen saturation before and after the procedure.
- B. Verify that the client has given informed consent.
- C. Explain the procedure briefly to the client and their family.
- D. Ensure informed consent has been obtained from the client.
Correct Answer: D
Rationale: The correct answer is D because ensuring informed consent is crucial before any invasive procedure to protect the client's autonomy and rights. This involves confirming the client's understanding of the procedure, risks, benefits, and alternatives. Option B is correct as it directly relates to the ethical and legal aspect of the procedure. Option A is incorrect as it focuses solely on monitoring oxygen saturation, which is important but not the priority before thoracentesis. Option C is incorrect as simply explaining the procedure does not ensure the client's understanding or consent.
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What is the definition of blindness in terms of the best corrected visual acuity (BCVA)?
- A. Less than 20/200 even with correction
- B. Between 20/70 and 20/200 in the better eye with glasses
- C. 20/400 or greater with no light perception
- D. 20/40 in at least one eye with correction
Correct Answer: A
Rationale: Blindness is legally defined as BCVA less than 20/200 in the better eye with correction.
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 with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?
- A. Would you like to talk more about this?
- B. You are lucky to have such a devoted daughter.
- C. It is normal to feel as though you are a burden.
- D. Would you like to meet with the chaplain?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and empathy, encouraging the client to express their feelings further. This response shows support and openness to discuss sensitive topics, promoting therapeutic communication. Choice B fails to address the client's emotional distress directly. Choice C may invalidate the client's feelings. Choice D may not be appropriate unless the client expresses interest in meeting with the chaplain. Overall, option A is the best response for addressing the client's emotional needs effectively.
Complications of overeating include which of the following?
- A. Hyperlipidemia
- B. Type I diabetes
- C. Sleep disturbances
- D. Rheumatoid arthritis
Correct Answer: A
Rationale: Overeating can lead to elevated cholesterol levels, contributing to hyperlipidemia and cardiovascular risks.
Because of the rapid elimination of volatile liquids used for general anesthesia, what should the nurse anticipate the patient will need early in the anesthesia recovery period?
- A. Warm blankets
- B. Analgesic medication
- C. Observation for respiratory depression
- D. Airway protection in anticipation of vomiting
Correct Answer: C
Rationale: Rapid elimination can lead to respiratory depression, necessitating close observation.