Nokea
To ensure safety while administering a nitroglycerine patch, the nurse should:
- A. Wear gloves while applying the patch.
- B. Shave the area where the patch will be applied.
- C. Wash the area thoroughly with soap and rinse with hot water.
- D. Apply the patch to the buttocks.
Correct Answer: A
Rationale: Gloves prevent the nurse from absorbing nitroglycerin, avoiding side effects.
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The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- A. Determine lung maturity
- B. Measure the fetal activity
- C. Show the effect of contractions on fetal heart rate
- D. Measure the well-being of the fetus
Correct Answer: D
Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
- A. PCO2 58
- B. SaO2 90
- C. PH 7.23
- D. HCO3 30
Correct Answer: C
Rationale: A pH of 7.23 indicates severe respiratory acidosis due to CO2 retention, a sensitive indicator for mechanical ventilation need in COPD. PCO2 and HCO3 are less immediate, and SaO2 is not critical.
A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan?
- A. Closed chest drainage
- B. A tracheostomy
- C. A Swan Ganz Monitor
- D. Percussion vibration and drainage
Correct Answer: A
Rationale: Closed chest drainage is used post-lobectomy to remove air and fluid from the pleural space, promoting lung re-expansion.
A client with a head injury has an intracranial pressure (ICP) monitor in place. Cerebral perfusion pressure calculations are ordered. If the client's ICP is 22 and the mean pressure reading is 70, what is the client's cerebral perfusion pressure?
- A. 92
- B. 72
- C. 58
- D. 48
Correct Answer: D
Rationale: Cerebral perfusion pressure (CPP) = Mean Arterial Pressure (MAP) - ICP. Given MAP = 70 and ICP = 22, CPP = 70 - 22 = 48. Thus, the answer is 48.
All of the following are parts of the middle ear EXCEPT the
- A. pinna.
- B. incus.
- C. stapes.
- D. malleus.
Correct Answer: A
Rationale: The middle ear includes the incus, stapes, and malleus (ossicles). The pinna is part of the outer ear.