Nokea
What is the primary complication of untreated otitis media?
- A. Hearing loss
- B. Meningitis
- C. Cholesteatoma
- D. All of the above
Correct Answer: D
Rationale: Untreated otitis media can lead to serious complications, including hearing loss, meningitis, and cholesteatoma.
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Which nursing interventions should not be delegated to unlicensed assistive personnel (UAP) but should be performed by the RN (select all that apply)?
- A. Administering patient medications
- B. Ambulating stable patients
- C. Performing patient assessment
- D. Evaluating the effectiveness of patient care
Correct Answer: A
Rationale: Medication administration, assessment, evaluation, and teaching require the RN's specialized knowledge and accountability.
What is the main drawback of the botulism antitoxin that the nurse should be aware of?
- A. It causes 9% hypersensitivity.
- B. It requires monthly booster dosages.
- C. It is not available from the CDC.
- D. It is not available as a pre-exposure vaccine.
Correct Answer: D
Rationale: The correct answer is D because botulism antitoxin is not available as a preventive vaccine.
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown:
- A. Ileostomy.
- B. Transverse colostomy.
- C. Ileal conduit.
- D. Sigmoid colostomy.
Correct Answer: A
Rationale: Ileostomies produce more caustic effluent, increasing skin irritation risk.
Which of the following would have the highest priority in septic shock?
- A. Monitoring temperature.
- B. Monitoring pupillary reaction.
- C. Monitoring airway, breathing, circulation (ABC).
- D. Monitoring ANA and RF levels.
Correct Answer: C
Rationale: Maintaining ABCs is critical in septic shock.
How should the nurse position Mr. Jones’ chest drainage unit while he is transported?
- A. Below the chest level
- B. On the stretcher
- C. The unit should be removed
- D. The tubes should be clamped
Correct Answer: A
Rationale: The correct answer is A: Below the chest level. Positioning the chest drainage unit below the chest level allows for effective drainage of air or fluid from the chest cavity. Placing it above the chest level may cause backflow or air/fluid accumulation. Option B is incorrect as the unit should be secured to prevent dislodging during transport. Option C is incorrect as removing the unit can lead to complications. Option D is incorrect as clamping the tubes can result in a tension pneumothorax. Positioning the unit below the chest level ensures proper drainage and prevents complications during transport.