Nokea
What special consideration should be taken into account when Mario prepares Richard for postural drainage and percussion?
- A. Monitoring a respiratory rate of 16 to 20 per minute
- B. Assessing the client's ability to tolerate sitting and lying positions
- C. Ensuring the client is free of signs of infection
- D. Knowing the time of the client's last food and fluid intake
Correct Answer: A
Rationale: The correct answer is A, 'Monitoring a respiratory rate of 16 to 20 per minute'. When performing postural drainage and percussion, it is crucial to monitor the respiratory rate to ensure the safety and effectiveness of the procedure. Choice B, 'Assessing the client's ability to tolerate sitting and lying positions', while important, is not directly related to the specifics of postural drainage and percussion. Similarly, option C, 'Ensuring the client is free of signs of infection', although important, is not directly linked to the procedure. Option D, 'Knowing the time of the client's last food and fluid intake', might be relevant for other procedures, but it is not the primary consideration for postural drainage and percussion.
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What effect does the use of a hot compress have, as explained to Ronnie who has been prescribed pain medication?
- A. It produces an anesthetic effect
- B. It increases nutrition in the blood to promote wound healing
- C. It increases oxygenation to the injured tissues for better healing
- D. It induces vasoconstriction to prevent infection
Correct Answer: A
Rationale: The correct answer is A: 'It produces an anesthetic effect.' Hot compresses can help alleviate pain by producing an anesthetic effect, which numbs the area. Choice B is incorrect because a hot compress does not directly increase nutrition in the blood to promote wound healing. Choice C is also incorrect because a hot compress primarily aids in pain relief rather than increasing oxygenation to the tissues for enhanced healing. Choice D is incorrect because hot compresses typically lead to vasodilation, not vasoconstriction, which aids in promoting blood flow rather than preventing infection. Safe and effective patient care relies on actions based on established nursing protocols that consider both the immediate and long-term needs of the patient.
When can a patient's medical record become a potential issue for the doctor or nurse?
- A. When the record is extensive
- B. When a medical record is subpoenaed in court
- C. When it is missing
- D. When the medical record is inaccurate, incomplete, or inadequate
Correct Answer: D
Rationale: The correct answer is D. A medical record becomes a potential issue for a doctor or a nurse when it is inaccurate, incomplete, or inadequate. This is because a medical record is a key tool for healthcare professionals to track a patient's history, treatment, and progress. If the record is not accurate or complete, it can lead to misdiagnosis, incorrect treatment, or other potential problems in patient care. While missing records (Choice C) could be a problem, they do not directly implicate the doctor or nurse in the same way that inaccurate or inadequate records do. An extensive record (Choice A) or a record being subpoenaed in court (Choice B) are not inherently problematic for healthcare professionals and do not necessarily reflect negatively on their work.
Which of the following interventions should be considered the highest priority when caring for June, who has hemiparesis secondary to a stroke?
- A. Position June in an upright lateral position
- B. Perform range of motion exercises
- C. Apply antiembolic stockings
- D. Use hand rolls or pillows for support
Correct Answer: C
Rationale: The correct answer is C, 'Apply antiembolic stockings'. In the case of a patient who has experienced a stroke and is suffering from hemiparesis, the highest priority intervention is to prevent further complications such as deep vein thrombosis (DVT), which can be life-threatening. Antiembolic stockings are used to increase venous blood flow velocity and reduce the risk of DVT. Choice 'A', positioning June in an upright lateral position, while important for overall care, is not the highest priority. Choice 'B', performing range of motion exercises, is an important part of recovery but not the immediate priority. Choice 'D', using hand rolls or pillows for support, is also a valuable intervention but does not address the most pressing risk of further complications.
What is the fundamental difference between nursing diagnoses and collaborative problems?
- A. Collaborative problems are managed by nurses using physician-prescribed interventions.
- B. Collaborative problems can be addressed by independent nursing interventions.
- C. Physician-prescribed interventions are incorporated into nursing diagnoses.
- D. Nursing diagnoses include physiologic complications that nurses monitor to detect status changes.
Correct Answer: B
Rationale: The correct answer is B, as collaborative problems necessitate the collective expertise and skills of numerous healthcare professionals, including nurses. These problems can be dealt with through independent nursing interventions in cooperation with other team members. Option A is incorrect because collaborative problems aren't strictly managed with physician-prescribed interventions. Option C is incorrect because nursing diagnoses aim at identifying and treating actual or potential health issues, rather than merely integrating physician-prescribed interventions. Option D is incorrect because nursing diagnoses aim at identifying patient issues, not solely physiologic complications, and guide the necessary nursing care, not just monitor for changes.
Which adolescent student lunch, evaluated by the school nurse, is the least nutritious?
- A. Ham sandwich, apple, and milk
- B. Hamburger, fries, and soft drink
- C. Macaroni and cheese, green beans, and peaches
- D. Meatloaf, broccoli, and pear slices
Correct Answer: B
Rationale: The correct answer is B: Hamburger, fries, and soft drink. This meal is considered the least nutritious among the options provided due to its high content of unhealthy fats, processed carbohydrates, and added sugars, which lack essential nutrients. On the other hand, choice A: Ham sandwich, apple, and milk, offers a balanced meal with protein, fiber, vitamins, and calcium. Choice C: Macaroni and cheese, green beans, and peaches, provides a mixture of carbohydrates, vegetables, and fruits. Choice D: Meatloaf, broccoli, and pear slices, includes protein, fiber, and vitamins. Thus, all choices except B provide a more balanced and nutritious meal.