Nokea
Two nurses are preparing to pull a client up in the bed. Which actions by the nurses are correct in regard to safe client handling? Select all that apply.
- A. place the bed in the lowest position possible
- B. ask the client to cross her arms over her chest if she is able
- C. use a patient lifting device, such as a Hoyer lift, if needed
- D. extend the elbows out away from the body while pulling client up
- E. place the head of the bed flat or slightly Trendelenburg if the client can tolerate it
Correct Answer: B, C, E
Rationale: Asking the client to cross arms, using a lifting device if needed, and flattening the bed or using slight Trendelenburg promote safe handling. The bed should be at working height, and elbows should stay close to the body.
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Nurses must be familiar with the American Nurses Association (ANA) Code of Ethics for Nurses. The nurse understands that which ethical principle is defined as the nurse's duty to do no harm? Fill in the blank.
- A. Nonmaleficence
- B. Bneficence
- C. autonomy
Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm, a core duty in nursing practice.
A preterm infant with sepsis is receiving Gentamycin (garamycin). Which physiological alteration places the preterm infant at increased risk for toxicity related to aminoglycoside therapy?
- A. Lack of subcutaneous fat deposits
- B. Immature central nervous system
- C. Presence of fetal hemoglobin
- D. Immaturity of the renal system
Correct Answer: D
Rationale: The immature renal system in preterm infants reduces the ability to excrete aminoglycosides like Gentamycin, increasing the risk of toxicity.
A client has been diagnosed with glossopharyngeal neuralgia. The nurse will expect the client to
- A. experience episodes of vertigo.
- B. experience difficulty moving the tongue.
- C. experience double vision.
- D. experience episodes of pain in the throat, ears, tongue, and tonsils.
Correct Answer: D
Rationale: Glossopharyngeal neuralgia causes severe pain in the throat, ears, tongue, and tonsils due to irritation of the ninth cranial nerve.
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 dexamethasone-suppression test has been ordered for a client with severe depression. The purpose of the dexamethasone suppression test is to:
- A. Determine which social intervention will be best for the client
- B. Help diagnose the seriousness of the client's clinical symptoms
- C. Determine whether the client will benefit from electroconvulsive therapy
- D. Reverse the depressive symptoms the client is experiencing
Correct Answer: B
Rationale: The dexamethasone suppression test assesses cortisol suppression to evaluate hypothalamic-pituitary-adrenal axis dysfunction, aiding in diagnosing severe depression.