Nokea
In a conscious trauma patient with a suspected head injury, which of the following actions is appropriate?
- A. Applying direct pressure to the wound.
- B. Administering aspirin for pain relief.
- C. Maintaining cervical spine immobilization.
- D. Assessing pupil reaction to light.
Correct Answer: C
Rationale: In a conscious trauma patient with a suspected head injury, maintaining cervical spine immobilization is crucial. The presence of a head injury raises concerns for potential concomitant cervical spine injury. Therefore, it is vital to prevent any movement of the cervical spine to avoid exacerbating a potential spinal cord injury. Maintaining immobilization involves stabilizing the patient's head and neck in a neutral position until appropriate imaging studies can assess the extent of any spinal injury. This action helps prevent further harm and ensures the safety of the patient during assessment and management of their injuries.
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Which of the following is a primary consideration in planning for her care?
- A. To prevent problems related to immobility
- B. To prevent infection
- C. Planning for client`s eventual inability communicate
- D. To prevent complications
Correct Answer: A
Rationale: When planning for a client's care, a primary consideration is to prevent problems related to immobility. Immobility can lead to a range of complications such as pressure ulcers, muscle weakness, joint contractures, and decreased circulation. To maintain the client's overall health and well-being, it is essential to address mobility issues and implement strategies to prevent complications associated with immobility. By prioritizing interventions that promote movement and prevent immobility-related problems, the client's quality of life can be improved and potential health risks mitigated.
Nurse Roberto assists in the care of a 30 year old male post surgical client undergoing nasogastric suctioning. The nurse understands that clients with nasogastric suction is MOST at risks with what imbalances?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Metabolic acidosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: Clients undergoing nasogastric suctioning are at highest risk for developing metabolic imbalances, specifically metabolic acidosis. Nasogastric suctioning can lead to the loss of gastric acid, which in turn can cause metabolic acidosis due to a decrease in bicarbonate levels in the body. This disruption in the acid-base balance can result in symptoms such as confusion, headache, and overall malaise. It is crucial for the nurse to monitor the client's acid-base status closely and provide appropriate interventions to prevent or correct metabolic acidosis.
Which of the following immune cells is primarily responsible for coordinating and regulating immune responses by producing cytokines that direct the activities of other immune cells?
- A. T helper cells (Th cells)
- B. Cytotoxic T cells (CTLs)
- C. B cells
- D. Natural killer (NK) cells
Correct Answer: A
Rationale: T helper cells (Th cells) are primarily responsible for coordinating and regulating immune responses by producing cytokines that direct the activities of other immune cells. These cytokines help in activating cytotoxic T cells, B cells, macrophages, and other cells involved in the immune response. Th cells play a crucial role in mounting an effective immune response against infections and diseases by providing the necessary signals to activate and control various immune cells. Thus, T helper cells are considered the central coordinators of the immune system.
A nurse is preparing to administer a nasogastric (NG) tube feeding for a patient. What action should the nurse prioritize before initiating tube feeding?
- A. Verifying the NG tube placement by auscultating for bowel sounds
- B. Securing the NG tube to prevent dislodgement during feeding
- C. Checking the patency of the NG tube by aspirating gastric contents
- D. Elevating the head of the bed to a semi-Fowler's position
Correct Answer: C
Rationale: The nurse should prioritize checking the patency of the NG tube by aspirating gastric contents before initiating tube feeding. This is important to ensure that the NG tube is in the correct position and that it is functioning properly. By aspirating gastric contents, the nurse can confirm that the tube is in the stomach and not in the lungs or surrounding tissues. If no gastric contents are obtained upon aspiration, it may indicate that the tube is not properly placed or may be occluded, which would require further assessment and intervention before proceeding with tube feeding. Checking the patency of the NG tube is a crucial step in ensuring the safety and effectiveness of enteral nutrition delivery.
When collecting evidence from a rape victim, the victim's clothing is removed and placed in a
- A. paper bag .
- B. Plastic bag
- C. Ziploc bag
- D. Trash bag
Correct Answer: A
Rationale: When collecting evidence from a rape victim, it is important to handle the victim's clothing properly to preserve any potential evidence. The preferred method is to remove the clothing and place them in a paper bag. Paper bags are used in order to prevent the alteration or degradation of any DNA evidence that may be present on the clothing. Paper bags allow the clothing to breathe and prevent the growth of mold or other contaminants that can occur in plastic bags or trash bags. Additionally, paper bags help preserve trace evidence such as fibers or hairs that may be crucial in the investigation of the case. It is essential to handle and store the clothing correctly to maintain the integrity of the evidence for the investigation and potential prosecution.