Nokea
The first priority to care for the patient with a new fracture includes assessing
- A. Respiratory rate and effort, as well as pulse.
- B. The fracture site for bleeding.
- C. For signs of infection at the wound site of an open fracture.
- D. For circulation and sensation distal to the fracture site.
Correct Answer: D
Rationale: Assessing circulation and sensation ensures no compromise to distal structures.
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What volume of fluid loss causes marked deterioration in hypovolemic shock?
- A. 30% to 40% (1500 mL to 2000 mL)
- B. 15% to 30% (750 mL to 1500 mL)
- C. 10% to 15% (500 mL to 750 mL)
- D. More than 40% (more than 2000 mL)
Correct Answer: B
Rationale: Loss of 15% to 30% of blood volume significantly impairs circulation and tissue perfusion.
A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Continue to monitor the client as this is an expected finding.
- B. Add more water to the suction control chamber of the drainage system.
- C. Verify that the suction regulator is on and check the tubing for leaks.
- D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Correct Answer: C
Rationale: The correct answer is C: Verify that the suction regulator is on and check the tubing for leaks.
Rationale:
1. Lack of bubbling in the suction control chamber indicates suction may not be working.
2. Checking the suction regulator ensures it is on and at the correct level for proper drainage.
3. Checking tubing for leaks ensures the system is intact and functioning properly.
4. This intervention addresses the potential issue of inadequate suction, which can affect the client's postoperative recovery.
Summary:
- Option A: Continuing to monitor is not appropriate as lack of bubbling suggests an issue with suction.
- Option B: Adding more water to the suction control chamber is unnecessary and does not address the root cause.
- Option D: Milking the chest tube is not recommended as it can cause trauma and dislodging clots may lead to complications.
Which quality of care measures influence the payment for health care services by third-party payers (select all that apply)?
- A. Clinical outcomes
- B. Regulatory agencies
- C. Use of evidence-based practice
- D. Occurrence of preventable conditions
Correct Answer: A
Rationale: Third-party payers prioritize clinical outcomes, evidence-based practice adoption, and minimizing preventable conditions to ensure value-based care.
For a client who has sustained recent blindness, which task(s) would be appropriate to delegate to the nursing assistant? (Choose all that apply.)
- A. Listen to the client express grief or loss.
- B. Assist client to ambulate in hall.
- C. Orient client to surroundings.
- D. Encourage independence.
Correct Answer: B
Rationale: Assisting with mobility is within the scope of practice for nursing assistants and ensures safety for the client.
Which teaching strategies should be used when it is difficult to reach the desired goals of the session (select all that apply)?
- A. DVD
- B. Role play
- C. Discussion
- D. Printed material
Correct Answer: B
Rationale: The correct answers are 'Role play,' 'Discussion,' and 'Lecture-discussion.' These strategies encourage active participation and engagement, which can help overcome barriers to achieving learning goals. DVDs and printed materials may not engage the patient as effectively in challenging situations.