Nokea
The hydraulic lift (Hoyer lift) is:
- A. used for all clients who've had orthopedic surgery.
- B. used for all clients who are not able to stand and for extremely obese clients.
- C. used for all clients, both old and young, in a hospital setting.
- D. not an assistive device for special needs.
Correct Answer: B
Rationale: The hydraulic lift is used for safe transfer when a client is not able to stand or is too heavy for the health care workers to lift safely.
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A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
- A. Verbal teaching in short sessions throughout the day.
- B. Pre-operative booklet on the surgery in Braille.
- C. Provide a tape for the client.
- D. Have the blind patient's family member instruct the patient.
Correct Answer: A
Rationale: Information is smaller amounts is easier to retain. Teaching the day before the procedure is best accomplished in a one on one format.
A nurse is assessing a 18 year-old female who has recently suffered a TBI. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing which of the following conditions?
- A. Increased intracranial pressure
- B. Increased function of cranial nerve X
- C. Sympathetic response to activity
- D. Meningitis
Correct Answer: A
Rationale: The patient is at high risk of developing increased intracranial pressure (ICP) due to the traumatic brain injury, which can cause a slower pulse and impaired respiration.
A wrong committed by one person against another (or against the property of another) that might result in a civil trial is:
- A. a tort.
- B. a crime.
- C. a misdemeanor.
- D. a felony.
Correct Answer: A
Rationale: Torts are wrongs committed by one person against another person (or against the property of another), which might result in civil trials. A crime is also defined as a wrong against a person or their property but is considered to be against the public as well. Misdemeanors are crimes that are commonly punishable with fines or imprisonment for less than one year, with both or with parole. A felony is a serious crime punishable by imprisonment in a State or Federal penitentiary for more than one year.
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed at least 30 degrees.
- B. If the residual is greater than 200 mL, the LPN should not administer the enteral feeding.
- C. The residual should be discarded prior to administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct Answer: C
Rationale: The residual should be injected back into the PEG tube, as it contains important enzymes and nutrients.
To remove a client's gown when she has an intravenous line, the nurse should:
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
- B. cut the gown with scissors.
- C. thread the bag and tubing through the gown sleeve, keeping the line intact.
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown.
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.