Nokea
The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:
- A. Administer a prescribed antibiotic
- B. Wash her hands for 2 minutes before care
- C. Wear a mask when providing care
- D. Ask the client to cover her mouth when she coughs
Correct Answer: B
Rationale: Hand washing is the most effective measure to prevent postoperative wound infections.
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A client's blood pressure is 132/84. What is the mean arterial pressure?
- A. 79 mmHg
- B. 48 mmHg
- C. 92 mmHg
- D. 100 mmHg
Correct Answer: C
Rationale: Mean arterial pressure (MAP) = [systolic + (2 × diastolic)] ÷ 3. Calculation: [132 + (2 × 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg. Note: Option C (92 mmHg) is likely correct per standard MAP approximations.
The nurse should carefully monitor the client for which common dysrhythmia that can occur during suctioning?
- A. Bradycardia
- B. Tachycardia
- C. Ventricular ectopic beats
- D. Sick sinus syndrome
Correct Answer: A
Rationale: Suctioning can stimulate the vagus nerve, leading to bradycardia due to parasympathetic activation, especially in clients with tracheostomies or endotracheal tubes.
A nurse manager is educating a group of nursing students about the Patient's Bill of Rights. The nurse knows that the student nurses have an understanding of the bill when one of the nurses makes which statement?
- A. Clients have the right to view their medical records but may not copy any of the information contained in the records.
- B. Clients may be declined care at an emergency department or need preauthorization for care if they do not have premium-level insurance.
- C. Clients have the right to a quick and objective review of any claim that they levy against a health care facility, physician, or health care plan.
- D. It is the admitting nurse's job to verify the client's past medical history, medications, and treatments, even if the client refuses to cooperate in giving the information.
Correct Answer: C
Rationale: The Patient’s Bill of Rights includes the right to a fair review of claims against healthcare providers. Other options are incorrect or misrepresent client rights.
A client is admitted with a possible bowel obstruction. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. Tell me about your pain.'
- B. What does your vomit look like?'
- C. Describe your usual diet.'
- D. Have you noticed an increase in abdominal size?'
Correct Answer: C
Rationale: Diet history is less directly related to diagnosing a bowel obstruction compared to pain, vomiting characteristics, or abdominal distension, which are hallmark symptoms.
What is the critical point for PO2 (the 'ICU' point), the percentage point at which there is marked decrease in oxygen saturation? Record your answer using a whole number.
Correct Answer: 90
Rationale: The critical PO2 point is around 90 mmHg, where oxygen saturation drops significantly, often requiring ICU intervention.