Nokea
The nurse administers cleansing enema. The common position for this procedure is...
- A. Sims left lateral
- B. Dorsal Recumbent
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sims left lateral allows easy access to the rectum and comfort during an enema.
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When a client's skin is dry, which of the following nursing interventions would be most helpful?
- A. Limit bathing to once or twice a week.
- B. Bathing is daily, but no soap is used.
- C. Bathing daily with mineral oil added to the water.
- D. Bathing with lotion instead of water.
Correct Answer: A
Rationale: Limiting bathing to once or twice weekly prevents further drying of already dry skin, preserving natural oils. Daily bathing, even without soap or with oil, risks exacerbation, and lotion isn't a bath substitute. Nurses apply this to maintain skin integrity.
The nurse is teaching the parent of an infant client about common pediatric conditions. Which statement by the nurse about otitis media is correct?
- A. Otitis media usually occurs before your child experiences a primary bacterial infection.'
- B. Some causes of otitis media can be prevented by administering a vaccine to your child.'
- C. Ear infections are very contagious and can also spread within your child's body.'
- D. If your infant uses a pacifier, it can prevent the development of otitis media.'
Correct Answer: B
Rationale: Otitis media (OM), middle ear infection, is often bacterial (e.g., Streptococcus pneumoniae). The correct statement is B: vaccines like PCV13 prevent some causes by targeting pathogens. A is false; OM typically follows infections. C is wrong; OM isn't highly contagious or systemic. D is incorrect; pacifiers increase OM risk. Rationale: Vaccines reduce OM incidence by immunizing against common bacteria, a key preventive strategy per AAP guidelines, unlike the other statements which misrepresent etiology or prevention.
Which of the following statement is NOT true about pulse pressure?
- A. Pulse pressure is the difference between the systolic and diastolic pressure
- B. Normal pulse pressure is 40 mmHg
- C. Pulse pressure increases when the systolic pressure is elevated and the diastolic pressure remains the same
- D. Elderly people have decreased pulse pressure due to loss of elasticity in the blood vessels
Correct Answer: D
Rationale: Pulse pressure is systolic minus diastolic (A), typically 40 mmHg (B), and rises if systolic increases with stable diastolic (C), per cardiovascular norms. Elderly have increased pulse pressure (D) due to arterial stiffness systolic rises, diastolic may drop making D untrue. Aging widens pulse pressure, not narrows it, contradicting D, thus it's the correct answer as the false statement.
When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?
- A. whoever is authorized by hospital policy
- B. the student nurse giving the client's care
- C. the student nurse's instructor
- D. any licensed nurse on duty
Correct Answer: A
Rationale: Hospital policy dictates who takes telephone orders, ensuring legal and safety compliance, typically a licensed nurse, not a student or instructor alone. This standard protects clients from errors by untrained personnel, aligning with nursing scope and institutional rules for accurate order execution.
A client has a mean arterial blood pressure (MAP) of $97 \mathrm{mmHg}$ and an intracranial pressure (ICP) of $12 \mathrm{mmHg}$. What is the cerebral perfusion pressure (CPP) for this client?
- A. 75
- B. 85
- C. 97
- D. 109
Correct Answer: B
Rationale: CPP = MAP - ICP; 97 - 12 = 85 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP measures brain perfusion; 85 mmHg is within normal (60-100 mmHg), critical for assessing adequacy post-injury, per neurocritical care formulas.