Nokea
What should govern the nurse’s actions regarding Mr. West rubbing Mrs. West’s calf?
- A. Touch is an important method of communication
- B. It is important to involve family members in patient care
- C. Massage increases circulation, therefore reducing tenderness
- D. A thrombus becomes an embolus when dislodged
Correct Answer: D
Rationale: Massaging the leg could dislodge a clot, leading to complications.
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Why is it important for a nurse to move a victim of a common respiratory toxin to higher ground immediately?
- A. The toxins flow to the lower ground.
- B. The toxic vapors stay close to the ground.
- C. The toxins are always released close to the ground.
- D. The heavy and the solid toxins cannot move to a height.
Correct Answer: B
Rationale: The correct answer is B because many respiratory toxins are heavier than air and settle near the ground.
A student nurse arrives on the unit and asks you what the rationale for treatment of withdrawal is. What is the best response?
- A. To protect the patient while the body removes the drug from the patient's bloodstream.
- B. To protect the patient from relapsing during withdrawal.
- C. To treat the patient's psychological dependency on the substance.
- D. To treat the symptoms of withdrawal while the body removes the substance from the patient's bloodstream.
Correct Answer: D
Rationale: Treating withdrawal symptoms supports physiological stability as the body clears the substance.
A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Perform range-of-motion exercises
- B. Place suction equipment at the bedside
- C. Encourage the use of an incentive spirometer
- D. Administer an expectorant
Correct Answer: C
Rationale: The correct answer is C: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications by promoting deep breathing and preventing atelectasis. A: Range-of-motion exercises do not directly prevent pulmonary complications. B: Placing suction equipment is important but does not prevent pulmonary complications. D: Administering an expectorant helps with mucus clearance but does not prevent pulmonary complications as effectively as using an incentive spirometer.
What observation would indicate the water-seal drainage system is working correctly?
- A. No bubbling of air in the suction control bottle
- B. Fluctuation of the fluid level in the tube of the water-seal bottle
- C. 25 ml of serosanguineous fluid has collected in the drainage bottle
- D. Excessive bubbling in the water-seal bottle
Correct Answer: B
Rationale: Fluctuation indicates proper lung expansion and absence of leaks.
What is the role of antiviral medications in treating herpes zoster ophthalmicus?
- A. Reduce viral replication
- B. Prevent bacterial infection
- C. Correct vision
- D. None of the above
Correct Answer: A
Rationale: Antivirals target the varicella-zoster virus, reducing its replication and severity.