Nokea
What is the nurse's priority for a client with an altered level of consciousness?
- A. Assess airway.
- B. Check reflexes.
- C. Monitor urine output.
- D. Perform a pain assessment.
Correct Answer: A
Rationale: Assessing the airway is the priority to ensure adequate oxygenation in a client with altered consciousness.
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A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud's phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these findings, the nurse should formulate which priority nursing diagnosis?
- A. Acute pain related to hyperemic stage
- B. Disturbed sensory perception (tactile) related to vasospastic process
- C. Ineffective tissue perfusion (peripheral) related to vasospastic process
- D. Risk for impaired skin integrity related to vasospastic process
Correct Answer: C
Rationale: Ineffective tissue perfusion (peripheral) is the priority nursing diagnosis in Raynaud's phenomenon, as vasospasm reduces blood flow to the extremities, causing ischemia. This underlies symptoms like numbness or pallor. Pain, sensory changes, or skin integrity risks are secondary to perfusion deficits.
A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding of the cause of hearing loss in older adults is related to:
- A. Accumulation of cerumen in the external canal.
- B. Accumulation of cerumen in the internal canal.
- C. External otitis.
- D. Exostosis.
Correct Answer: A
Rationale: Accumulation of cerumen in the external canal is a common cause of conductive hearing loss in older adults, leading to a sensation of fullness and reduced hearing.
During rescue breathing in cardiopulmonary resuscitation (CPR), the victim will exhale by:
- A. Normal relaxation of the chest.
- B. Gentle pressure of the rescuer's hand on the upper chest.
- C. The pressure of cardiac compressions.
- D. Turning the head to the side.
Correct Answer: A
Rationale: Exhalation during CPR occurs naturally due to chest relaxation after the rescuer delivers a breath, allowing air to exit the lungs.
The nurse is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?
- A. A review in the Cochrane Library.
- B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINHAL).
- C. An online nursing textbook.
- D. The online policy and procedure manual at the health care agency.
Correct Answer: A
Rationale: The Cochrane Library provides high-quality, evidence-based systematic reviews, making it the most reliable resource for developing standards of care.
When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her doctor that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because:
- A. The prosthesis may cause a problem with the electrosurgical unit used to control bleeding.
- B. The client should not have her hip externally rotated when she is positioned for the procedure.
- C. The perioperative nurse can inform the rest of the team about the total hip replacement.
- D. There is not enough time to notify the surgeon and note this finding on the history and physical information before the procedure.
Correct Answer: A
Rationale: A hip prosthesis can conduct electricity from an electrosurgical unit, risking burns or complications. Communicating this ensures precautions are taken during surgery.