Nokea
The nurse explains to the patient that the primary purpose of such a record is to
- A. Reduce the cost of health care by eliminating paper records
- B. Prevent medical errors associated with traditional paper records and handwritten orders and prescriptions
- C. Force the use of standardized medical vocabularies and nursing terminologies so that outcomes of patient care can be measured
- D. Provide a single record in which all aspects of a patient’s medical information are readily available to any health care provider involved in the patient’s care
Correct Answer: D
Rationale: Electronic health records centralize patient data, ensuring all providers have access to complete and up-to-date information.
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Three days after surgery, Mark notices that the wound site is more painful now than it was the day before. When you inspect the surgical site you are looking for redness or inflammation. Other indicators of infection would include:
- A. Elevated RBC and elevated respiratory rate.
- B. Elevated WBC and elevated temperature.
- C. Elevated erythrocyte sedimentation rate and decreased pulse.
- D. Decreased platelets and decreased blood pressure.
Correct Answer: B
Rationale: Elevated white blood cell (WBC) count and fever are classic signs of infection. These indicators suggest the body is mounting an immune response to a potential pathogen.
What accurately describes the health care system in which future nurses will be employed?
- A. With improvements in medicine there will be fewer patients with chronic illnesses
- B. Rapidly changing technology and expanding knowledge will simplify the health care environment
- C. The Quality and Safety Education for Nurses (QSEN) project measures the ability of nursing graduates to be prepared for the reality of practice
- D. The Joint Commission establishes National Patient Safety Goals and evidence-based solutions for nurses to promote meeting these goals by all caring for the patient
Correct Answer: C
Rationale: The QSEN project focuses on preparing nurses for real-world practice, and The Joint Commission sets safety goals. Chronic illnesses are increasing due to aging populations, and technology adds complexity rather than simplifying the environment.
Mrs. Smith asks about treatment options for sensorineural deafness. To counsel Mrs. Smith appropriately, the nurse knows that the only type of organically caused deafness that can be effectively treated at this time is
- A. conductive deafness
- B. sensorineural deafness
- C. central deafness
- D. mixed-type deafness
Correct Answer: A
Rationale: Conductive deafness often responds well to surgical or medical interventions, unlike other types of hearing loss where treatment options are limited.
A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?
- A. Rest in a side-lying position after the tube is removed.
- B. Use the incentive spirometer every 4 hours after the tube is removed.
- C. Avoid speaking for extended periods.
- D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.
Correct Answer: C
Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications.
Step-by-step rationale:
1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage.
2. It is essential to allow the airway to recover and prevent irritation or inflammation.
3. Resting the voice can aid in the healing process and reduce the risk of complications.
4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest.
5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications.
6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.
While assessing a client with pulmonary tuberculosis, which of the following findings should the nurse expect?
- A. Lethargy
- B. High-grade fever
- C. Weight gain
- D. Dry cough
Correct Answer: A
Rationale: The correct answer is A: Lethargy. In pulmonary tuberculosis, lethargy is common due to systemic symptoms like fatigue and weakness. High-grade fever is also common but not specific to pulmonary tuberculosis. Weight loss, not weight gain, is a classic symptom due to decreased appetite. Dry cough is a common symptom, but not as specific as lethargy in pulmonary tuberculosis.