Nokea
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
- A. Performing oral care every 4 hours.
- B. Elevating the head of the bed to 30-45 degrees.
- C. Administering prophylactic antibiotics.
- D. Suctioning the endotracheal tube every 2 hours.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.
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The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. Monday and end at 7 a.m. Tuesday?
- A. Collect and save the urine voided at 7 a.m. on Monday.
- B. Send the first voided urine specimen on Monday to the laboratory for culture.
- C. Collect and save the urine voided at 7 a.m. on Tuesday.
- D. Keep each day's urine collection in separate containers.
Correct Answer: C
Rationale: The 24-hour collection includes all urine from after the 7 a.m. Monday void (discarded) to the 7 a.m. Tuesday void (included).
The nurse talks to students at a high school about sexually transmitted infections (STIs). Which effective methods of preventing STIs does the nurse include in the discussion? Select all that apply.
- A. Some birth control pills prevent STIs.
- B. STIs do not transmit through oral sex.
- C. Diaphragms are a barrier against STIs.
- D. Abstinence prevents transmission of STIs.
- E. Proper condom use provides STI protection.
- F. Multiple sex partners increase the risk of STIs.
Correct Answer: D,E,F
Rationale: Effective measures to avoid STIs include abstinence, using condoms properly, and avoiding multiple partners, and the nurse should provide this factual information to the high school students. The nurse also includes information about ineffective methods of preventing STIs, including birth control pills, oral sex, and diaphragms.
How many units of heparin would you administer subcutaneously using the below information? Doctor's order: 6,500 units of heparin subcutaneously Medication label: 4,500 units in one mL
- A. 1.4 mL
- B. 1.5 mL
- C. 1.475 mL
- D. 1.425 mL
- E. 1.375 mL
Correct Answer: A
Rationale: To calculate: 6,500 units ÷ 4,500 units/mL = 1.444 mL, rounded to 1.4 mL for practical administration.
A client being treated for a comminuted fractured tibia asks the nurse to explain what a comminuted fracture means. The nurse should give which response?
- A. It means the fracture is incomplete.
- B. It means the bone is partially fractured.
- C. It means the bone fractured with splintering of the bone into fragments.
- D. It means the skin or mucous membrane was broken when the fracture occurred.
Correct Answer: C
Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent. A compound fracture, also called an open fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone.
When developing the plan of care for a 12-year-old child who is to receive 48 hours of chemotherapy that is associated with nausea and vomiting, at which of the following times should the nurse anticipate administering an antiemetic?
- A. Immediately following chemotherapy.
- B. 30 minutes before the chemotherapy starts, then every 4 to 6 hours.
- C. When the 12-year-old requests medication for nausea, then every 4 hours as needed.
- D. On starting the chemotherapy infusion, and then routinely every 8 hours.
Correct Answer: B
Rationale: Administering an antiemetic 30 minutes before chemotherapy and every 4-6 hours prophylactically minimizes nausea and vomiting.