Nokea
What is the first sign that the condition of a dying client is worsening?
- A. Pulmonary function impairment
- B. Peripheral circulation changes
- C. Central nervous system alterations
- D. Failing cardiac function
Correct Answer: C
Rationale: Central nervous system changes, such as confusion or lethargy, often indicate declining health in terminal stages.
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A patient is brought into the ER. The patient's BAL is 0.48 and the patient is unconscious. What is the first thing you do?
- A. Place the patient in a quiet area and wait until the patient begins to sober before continuing your assessment.
- B. Call the ED practitioner immediately.
- C. Administer Narcan to the patient.
- D. Send the patient to ICU immediately.
Correct Answer: B
Rationale: Immediate notification of the ED practitioner ensures prompt intervention for a life-threatening condition.
Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?
- A. Position the head of the client's bed flat
- B. Turn the client every 4 hours
- C. Brush the client's teeth with a suction toothbrush every 12 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: C
Rationale: The correct answer is C: Brush the client's teeth with a suction toothbrush every 12 hours. This is crucial in reducing the risk of ventilator-associated pneumonia as it helps prevent the buildup of bacteria in the oral cavity, which can be aspirated into the lungs. Brushing the teeth regularly maintains oral hygiene, decreasing the chances of infection.
A: Positioning the head of the client's bed flat can increase the risk of aspiration and pneumonia.
B: Turning the client every 4 hours is important for preventing pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia.
D: Providing humidity within the ventilator tubing is important for preventing mucous plugs but does not directly address oral hygiene, which is key in preventing pneumonia.
What is your evaluation of Mr. Smith’s skin rash and slight fever after taking INH for 3 months?
- A. Is developing hepatitis
- B. Has not been taking INH
- C. Is having a normal response to the medication
- D. Is demonstrating early signs of drug hypersensitivity
Correct Answer: D
Rationale: The correct answer is D because Mr. Smith's skin rash and slight fever after taking INH for 3 months indicate early signs of drug hypersensitivity. This is supported by the timing of symptoms appearing after prolonged use, which is typical for drug hypersensitivity reactions. Other choices are incorrect: A, developing hepatitis would show different symptoms; B, not taking INH would not explain the symptoms; C, a normal response would not involve rash and fever.
Instructions for a patient at risk for testicular cancer include
- A. Restrict potassium, phosphate, sodium, protein in diet.
- B. Self-catheterization of ileal reservoir.
- C. Testicular self-exam.
- D. Change in color of urine is to be expected.
Correct Answer: C
Rationale: Regular self-exams help detect testicular cancer early.
You are reviewing your client's understanding of the post-operative stapedectomy instructions that you gave several days ago. Which comment concerns you the most?
- A. I'm going to take swimming lessons in a couple of months.'
- B. I have to take a long overseas flight in several weeks.'
- C. I can't wait to get back to my regular weightlifting class.'
- D. I have been coughing a lot with my mouth open.'
Correct Answer: C
Rationale: Weightlifting can increase intracranial pressure and compromise the surgical site, posing a risk to recovery.