Nokea
What nursing interventions increase the risk the pressure injuries?
- A. Padding hard surfaces
- B. Have client sit in wheelchair as much as possible
- C. Place pillows between bony surfaces
- D. Keep head of bed (HOB) at or less than 3
Correct Answer: B
Rationale:
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A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?
- A. Once retinal detachment occurs, it does not return to its normal state
- B. Once the tissue has necrosed from high-pressure, it does not regenerate
- C. Glaucoma always leads to permanent blindness
- D. Once bacterial infection has caused damage, the tissue does not regenerate
Correct Answer: B
Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.
A nurse enters the hospital room of a client with reduced immunity. What
observation requires further action by the nurse?
- A. The client is in a private room.
- B. The client has a vase of fresh flowers on the table
- C. The client has a dedicated vital signs machine
- D. There is hand sanitizer by the door
Correct Answer: B
Rationale:
A nurse is admitting a client who has tuberculosis. What transmission-based
precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective
Correct Answer: C
Rationale:
A client is in the emergency room in critical condition and hypotensive. Her
spouse is distraught. What is the priority nursing action?
- A. Maintain the client's blood pressure
- B. Call a chaplain
- C. Provide the spouse a chair
- D. Ask the client's spouse to explain what happened
Correct Answer: A
Rationale:
The quality and risk nurse in the local hospital is performing a hospital survey
on sentinel events. Which statements would the nurse use to best describe a
sentinel event?
- A. Operating room event involving the use of unsafe equipments
- B. Specific events that enable a hospital to maximize reimbursement
- C. An unexpected event involving death or serious physical or psychological injury
- D. An event that can cause serious injury to a client that should never happen in a
hospital
Correct Answer: C
Rationale: