Nokea
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy at home. What should the nurse include in the client's teaching regarding oxygen safety?
- A. Ensure you have a fire extinguisher readily available
- B. Keep the oxygen tubing loose to prevent tangling
- C. Avoid using electric heating devices in your home
- D. Use an oxygen concentrator for outdoor activities
Correct Answer: C
Rationale: Avoiding electric heating devices (C) is critical in COPD oxygen therapy teaching, as oxygen accelerates combustion, posing a fire risk. Fire extinguisher (A) is supplementary. Loose tubing (B) risks disruption. Concentrator use (D) depends on need. Safety education, per home care standards, prioritizes fire prevention.
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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.
A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
- A. Writing down all assignments
- B. Making changes after evaluating the situation and having discussions with the staff
- C. Telling the staff nurses that she is making changes to benefit their performance
- D. Evaluating the clinical performance of each staff nurse in a private conference
Correct Answer: B
Rationale: Evaluating and discussing changes eases transition and builds trust.
Too narrow cuff will cause what change in the Client's BP?
- A. True high reading
- B. True low reading
- C. False high reading
- D. False low reading
Correct Answer: C
Rationale: A narrow cuff e.g., under-sized overcompresses, yielding a false high BP e.g., 140/90 vs. true 120/80. True readings need proper fit; wide cuffs may lower falsely. Nurses select cuffs e.g., per arm size for accuracy, per measurement standards.
Mr. Gary stopped his meds and used herbal treatment instead. This is an example of?
- A. Alternative therapy
- B. Complementary therapy
- C. Patient education
- D. Managed care
Correct Answer: A
Rationale: Stopping meds for herbs is alternative therapy (A) replacing conventional, per definition. Complementary (B) combines, education (C) teaches, managed (D) costs not replacement-specific. A fits full switch, making it correct.
While planning nursing process for a patient who is at risk for suicide, which of the following is the priority area for providing care :
- A. Sleep
- B. Nutrition
- C. Self-esteem
- D. Safety
Correct Answer: D
Rationale: Suicide risk demands a prioritized nursing approach under the nursing process. Sleep (choice A) and nutrition (choice B) are basic needs, but disruptions are secondary to immediate risk. Self-esteem (choice C) influences mental health, yet addressing it is a longer-term goal. Safety (choice D) is the priority, as suicidal ideation poses an acute threat to life, requiring immediate interventions like removing hazards, constant observation, and risk assessment (e.g., SAD PERSONS scale). D is correct because ensuring safety prevents harm, the first step in stabilizing the patient. Nurses must implement safety protocols, collaborate with psychiatry, and then address sleep, nutrition, and esteem, building a comprehensive care plan.