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What should a nurse include in the teaching plan for clients who have a potential for hypovolemia?
- A. Avoid alcohol and caffeine
- B. Increase intake of dried peas and beans
- C. Increase intake of milk and dairy products
- D. Avoid table salt or food containing sodium
Correct Answer: A
Rationale: Alcohol and caffeine are diuretics, increasing fluid loss and worsening hypovolemi Avoiding them helps maintain fluid balance.
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Which theorist discussed adaptive and maladaptive behaviors?
- A. F. Skinner
- B. Harry Stack Sullivan
- C. Erik Erikson
- D. Sigmund Freud
Correct Answer: A
Rationale: F. Skinner's behaviorist theory emphasizes how behaviors are learned through reinforcement and punishment.
To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do?
- A. Encourage deep breathing
- B. Elevate the head of the bed
- C. Administer oxygen per mask
- D. Position the patient in a side-lying position
Correct Answer: D
Rationale: Side-lying position prevents tongue obstruction and facilitates drainage of secretions.
A patient with a breast biopsy positive for cancer tells the nurse that she has been using information from the Internet to try to make a decision about her treatment choices. In counseling the patient, the nurse knows that (select all that apply)
- A. the patient should be taught how to identify reliable and accurate information available online.
- B. all sites used by the patient should be evaluated by the nurse for accuracy and appropriateness of the information.
- C. most information from the Internet is incomplete and inaccurate and should not be used to make important decisions regarding treatment.
- D. the Internet is an excellent source of health information, and online education programs can provide patients with better instruction than is available at clinics.
Correct Answer: A
Rationale: The correct answers are 'the patient should be taught how to identify reliable and accurate information available online' and 'the patient should be encouraged to use sites established by universities, the government, or reputable health organizations, such as the American Cancer Society, to access reliable information.' These options promote the use of credible sources while discouraging reliance on potentially unreliable information.
While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30°.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
A patient scheduled for hip replacement surgery in the early afternoon is NPO but receives and ingests a breakfast tray with clear liquids on the morning of surgery. What response does the nurse expect when the anesthesia care provider is notified?
- A. Surgery will be done as scheduled.
- B. Surgery will be rescheduled for the following day.
- C. Surgery will be postponed for 8 hours after the fluid intake.
- D. A nasogastric tube will be inserted to remove the fluids from the stomach.
Correct Answer: A
Rationale: Clear liquids are generally acceptable up to 2 hours before surgery, allowing the procedure to proceed as planned.