Nokea
Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?
- A. Opening the patient's window to the outside environment
- B. Turning on the patient's room ventilator
- C. Opening the door of the patient's room leading into the hospital corridor
- D. Failing to wear gloves when administering a bed bath
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which of the following procedures always requires surgical asepsis?
- A. Vaginal instillation of conjugated estrogen
- B. Urinary catheterization
- C. Nasogastric tube insertion
- D. Colostomy irrigation
Correct Answer: B
Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.
During a Romberg test, the patient is asked to assume which position?
- A. Sitting
- B. Standing
- C. Genupectoral
- D. Trendelenburg
Correct Answer: B
Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.
What is the most common injury among elderly persons?
- A. Atherosclerotic changes in the blood vessels
- B. Increased incidence of gallbladder disease
- C. Urinary Tract Infection
- D. Hip fracture
Correct Answer: D
Rationale: Hip fracture is the most common injury among elderly persons. As people age, their bones become more fragile, making them more susceptible to hip fractures, often resulting from falls. These fractures can significantly impact an elderly person's quality of life and mobility, making them a significant concern in geriatric care.
When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?
- A. Discourage them from deciding until their grief has eased
- B. Listen to their concerns and answer their questions truthfully
- C. Urge them to immediately sign the consent form
- D. Inform them that the body will not be available for a wake or funeral
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.