Nokea
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.
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The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler's position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
- A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
- B. Place a humidifier in the patient's room
- C. Continue administering oxygen by high humidity face mask
- D. Perform chest physiotherapy on a regular schedule
Correct Answer: D
Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.
What is the primary purpose of a platelet count?
- A. Assessing clot formation potential
- B. Assessing bleeding risk
- C. Detecting antigen-antibody response
- D. Identifying cardiac enzymes presence
Correct Answer: B
Rationale: A platelet count is primarily used to assess the risk of bleeding. Platelets play a crucial role in blood clotting, so a low platelet count can lead to an increased risk of bleeding. Monitoring platelet levels helps healthcare providers evaluate a patient's ability to form clots and manage bleeding.
Which of the following blood tests should be performed before a blood transfusion?
- A. Prothrombin and coagulation time
- B. Blood typing and cross-matching
- C. Bleeding and clotting time
- D. Complete blood count (CBC) and electrolyte levels
Correct Answer: B
Rationale: Before administering a blood transfusion, it is crucial to perform blood typing and cross-matching to ensure compatibility between the donor's blood and the recipient's blood. This process helps prevent adverse reactions such as transfusion reactions, which can be life-threatening. Prothrombin and coagulation time, bleeding and clotting time, as well as CBC and electrolyte levels are important tests in other clinical contexts, but for blood transfusions, blood typing and cross-matching are essential to ensure patient safety.
The four main concepts common to nursing that appear in each of the current conceptual models are:
- A. Person, nursing, environment, medicine
- B. Person, health, nursing, support systems
- C. Person, health, psychology, nursing
- D. Person, environment, health, nursing
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In Maslow's hierarchy of physiological needs, the human need of greatest priority is:
- A. Love
- B. Elimination
- C. Nutrition
- D. Oxygen
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.