Nokea
What is your evaluation of Mr. Singer not covering his stoma?
- A. Has totally accepted his condition
- B. Is unwilling to comply with his prescribed regimen
- C. Does not understand its impact upon his health status
- D. Is embarrassed about his condition
Correct Answer: C
Rationale: Covering the stoma protects against infections and foreign objects.
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The nurse understands that during the 'tension building' phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of:
- A. Anger.
- B. Helplessness.
- C. Calm.
- D. Explosive.
Correct Answer: B
Rationale: Victims often feel powerless and trapped during this phase.
A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?
- A. Withhold food and liquids until the client's gag reflex returns.
- B. Irrigate the client's throat every 4 hours.
- C. Have the client refrain from talking for 24 hours.
- D. Suction the client's oropharynx frequently.
Correct Answer: A
Rationale: The correct answer is A: Withhold food and liquids until the client's gag reflex returns. After a flexible bronchoscopy, the client may have a decreased gag reflex due to topical anesthesia used during the procedure, which increases the risk of aspiration. Withholding food and liquids helps prevent aspiration until the gag reflex returns, usually within 1-2 hours.
B: Irrigating the client's throat every 4 hours is unnecessary and may not be indicated post-bronchoscopy.
C: Having the client refrain from talking for 24 hours is not necessary after a flexible bronchoscopy unless specifically instructed by the healthcare provider.
D: Suctioning the client's oropharynx frequently is not indicated unless there is a clinical indication for it, such as excessive secretions or respiratory distress. Frequent suctioning can increase the risk of trauma to the airway.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
- A. Initiating oxygen therapy
- B. Providing immediate rest for the client
- C. Positioning the client in high-Fowler's
- D. Administering a nebulized beta-adrenergic
Correct Answer: D
Rationale: The correct answer is D: Administering a nebulized beta-adrenergic. This is the highest priority because it directly addresses the acute asthma exacerbation by helping to open up the airways and improve breathing. Step 1: Assess the client's respiratory status Step 2: Administering the nebulized beta-adrenergic medication to relieve bronchospasm and improve airflow Step 3: Monitor the client's response to the medication and adjust care accordingly. Other choices are incorrect because A: Oxygen therapy may be needed but addressing the bronchospasm is the priority. B: Rest is important but not the priority in managing an acute asthma exacerbation. C: Positioning is helpful but not the priority over administering the medication to improve breathing.
A confirmatory laboratory test for HIV includes
- A. Western blot.
- B. Low WBC.
- C. Comprehensive metabolic panel.
- D. Enzyme-linked immunosorbent assay (ELISA).
Correct Answer: A
Rationale: Western blot is used to confirm HIV infection.
What general appearance and obvious physical characteristic components should the nurse evaluate when completing a biocultural assessment?
- A. Skin color,bone structure and eye shape.
- B. Mobility and gait.
- C. Behavioral patterns.
- D. All of the above.
Correct Answer: D
Rationale: Evaluating multiple aspects of physical appearance provides a comprehensive understanding of the client's biocultural context.