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What should be included in Mr. Dean’s teaching plan for respiratory isolation?
- A. Using disposable tissues for his respiratory secretions
- B. Reporting any allergies to the staff
- C. Asking family and friends not to visit
- D. Getting the patient out of bed frequently
Correct Answer: A
Rationale: Disposable tissues prevent the spread of pathogens.
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Karen is suspected of having a hormone imbalance. What would you expect to monitor
- A. Electrolyte levels.
- B. Thyroid studies, follicle-stimulating hormone (FSH), and luteinizing hormone (LH).
- C. Caloric intake.
- D. All of the above.
Correct Answer: D
Rationale: Hormonal imbalances affect multiple systems and require comprehensive monitoring.
Why is it important to acknowledge the 'comfort zone' of a client? How can a nurse relieve a client’s anxiety about physical closeness?
- A. To ensure the client feels respected and safe.
- B. To maintain professional distance.
- C. To facilitate quicker recovery.
- D. To comply with hospital policies.
Correct Answer: A
Rationale: Acknowledging a client's comfort zone respects their personal boundaries, reducing anxiety and promoting a trusting environment.
The patient asks you what the clip on his finger is for. The best response is
- A. This is a cardiac monitor that alerts us to any arrhythmia that you might experience during the night.
- B. This measures your temperature.
- C. This is pulse oximetry and is used to give us an idea of how much oxygen is in your blood.
- D. This tells us the number of red blood cells you have. These cells provide oxygen throughout your body.
Correct Answer: C
Rationale: Pulse oximetry measures oxygen saturation in the blood.
Tom reports abdominal pain that started over the periumbilical area and moved to the right lower quadrant area. Tom probably has
- A. Crohn's disease.
- B. Cholecystitis.
- C. Appendicitis.
- D. Diverticulitis.
Correct Answer: C
Rationale: Appendicitis typically presents with migrating pain from the periumbilical area to the right lower quadrant.
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Oxygen saturation of 95%
- B. No fluctuations in the water seal chamber
- C. No reports of pleuritic chest pain
- D. Occasional bubbling in the water-seal chamber
Correct Answer: B
Rationale: The correct answer is B: No fluctuations in the water seal chamber. This finding indicates that the lung has re-expanded because it means there is no air leaking from the lung into the pleural space, causing fluctuations in the water seal chamber. Option A, oxygen saturation of 95%, is not directly related to lung re-expansion. Option C, no reports of pleuritic chest pain, is a subjective symptom and does not provide a direct indication of lung re-expansion. Option D, occasional bubbling in the water-seal chamber, indicates air is escaping from the lung into the pleural space, suggesting incomplete lung re-expansion.