Nokea
Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
- A. Side rails are ineffective
- B. Side rails should not be used
- C. Side rails are a deterrent that prevents a patient from falling out of bed
- D. Side rails are a reminder to a patient not to get out of bed
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which of the following statements is incorrect about a patient with dysphagia?
- A. The patient will find pureed or soft foods, such as custards, easier to swallow than water
- B. Fowler's or semi Fowler's position reduces the risk of aspiration during swallowing
- C. The patient should always feed himself
- D. The nurse should perform oral hygiene before assisting with feeding
Correct Answer: C
Rationale: The incorrect statement is that 'The patient should always feed himself.' Patients with dysphagia may require assistance with feeding due to difficulty in swallowing safely. It is essential to provide appropriate support and supervision during meal times to prevent complications such as aspiration or inadequate nutrition intake.
Which deficiency is most commonly seen in individuals with alcohol use disorder?
- A. Thiamine
- B. Riboflavin
- C. Pyridoxine
- D. Pantothenic acid
Correct Answer: A
Rationale: Thiamine deficiency, also known as Vitamin B1 deficiency, is the most common vitamin deficiency seen in individuals with alcohol use disorder. Chronic alcohol consumption can lead to decreased thiamine absorption and utilization, as well as poor dietary intake. Thiamine deficiency can result in serious neurological complications, such as Wernicke-Korsakoff syndrome, making it essential to address thiamine supplementation in individuals with alcohol use disorder.
For abdominal inspection, in which of the following positions should a patient be placed?
- A. Prone
- B. Trendelenburg
- C. Supine
- D. Side-lying
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler's position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
- A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
- B. Place a humidifier in the patient's room
- C. Continue administering oxygen by high humidity face mask
- D. Perform chest physiotherapy on a regular schedule
Correct Answer: D
Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.
To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?
- A. Less than 30 ml/hour
- B. 64 ml in 2 hours
- C. 90 ml in 3 hours
- D. 125 ml in 4 hours
Correct Answer: A
Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.