Nokea
The method of splinting is always dictated by:
- A. Location of the injury and whether it is open or closed
- B. The severity of the client's condition and the priority decision
- C. The number of available rescuers and the type of splints
- D. All of the above
Correct Answer: B
Rationale: The severity of the client's condition and priority decision dictate splinting to ensure stabilization and prevent further injury, taking precedence over location or resources.
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Which of these statements from the caregiver of a palliative care client indicates a proper understanding?
- A. This treatment plan usually means the prognosis is less than 6 months.
- B. We will need to stay in the hospital to receive this level of care.
- C. The main therapeutic goals are comfort and better quality of life.
- D. The medications to treat the underlying disease will be stopped.
Correct Answer: C
Rationale: The goal of palliative care is to make the client as comfortable as possible and not require a hospital stay. Prognoses vary and curative treatments can still be pursued during palliative care.
The nurse is caring for the 11-month-old infant with bronchopulmonary dysplasia. The infant has 30% supplemental oxygen provided via a tracheostomy. Which action should the nurse take when the infant has a decline in oxygen saturation from 96% to 87% and appears anxious and restless?
- A. Obtain arterial blood gases (ABGs)
- B. Increase oxygen rate from 30% to 50%
- C. Suction the tracheostomy tube
- D. Medicate for anxiety and pain
Correct Answer: C
Rationale: C: Suctioning clears potential airway obstructions causing desaturation. A: ABGs are secondary if suctioning resolves distress. B: Increasing oxygen is ineffective with an occluded airway. D: Medication doesn't address airway issues.
The client voided 300 mL after having an indwelling urinary catheter removed six hours ago. A bladder scan immediately after the void showed that the client has a postvoid residual (PVR) volume of 250 mL. What should the nurse conclude from this finding?
- A. This is an expected finding following catheter removal.
- B. The client's bladder function is approximately 50% of normal.
- C. The bladder scan was not done within 20 minutes of voiding.
- D. The PVR volume is evidence of incomplete bladder emptying.
Correct Answer: D
Rationale: D: A PVR of 250 mL indicates incomplete bladder emptying, as normal PVR is less than 50 mL. A: High PVR is not expected. B: PVR doesn't quantify bladder function percentage. C: No evidence suggests timing was incorrect.
The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
- A. Wear sterile gloves to remove the lower plate first and then the upper plate.
- B. Use a foam swab to pry the upper and lower plates loose before removing these.
- C. Grasp the upper plate at the front teeth with a piece of gauze and move it prior to removal.
- D. Leave the dentures in the client's mouth and use a toothbrush to brush both denture plates.
Correct Answer: C
Rationale: C: Grasping the upper plate and moving it breaks the suction that holds the plate on the roof of the client's mouth. A: Removing denture plates is a clean procedure, and sterile gloves are not necessary. B: Removing the denture plates with a foam swab to pry the plate could injure the client. D: Dentures must be removed to properly clean the client's mouth and the dentures.
Major competencies for the nurse giving end-of-life care include:
- A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client.
- B. assessing and intervening to support total management of the family and client.
- C. setting goals, expectations, and dynamic changes to care for the client.
- D. keeping all sad news away from the family and client.
Correct Answer: A
Rationale: There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies.