Nokea
When a client is having a general tonic clonic seizure, the nurse should:
- A. Hold the client's arms at their side.
- B. Place the client on their side.
- C. Insert a padded tongue blade in client's mouth.
- D. Elevate the head of the bed.
Correct Answer: B
Rationale: Placing the client on their side prevents aspiration.
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Mary asks how the pulmonary function test ordered by her physician is performed. You respond by saying
- A. You breathe into a spirometer to measure your lung capacity.
- B. You breathe through a mouthpiece into a spirometer until all air in your lungs is expelled; then you take a deep breath through the mouthpiece. This is done three times and a computer calculates the capacity of your lungs.
- C. A computer is used to measure your volume and vital capacity.
- D. A tube is inserted into your lungs while you are asleep to expand your lungs to their full capacity.
Correct Answer: B
Rationale: Pulmonary function tests measure lung capacity using spirometry.
To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to
- A. avoid crowds and obtain an annual influenza vaccination.
- B. drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
- C. eat a potassium-rich, low-sodium diet.
- D. practice good dental hygiene and report gum swelling or bleeding.
Correct Answer: D
Rationale: Phenytoin can cause gum hyperplasia, so good dental hygiene is essential.
A client is postoperative following an intermaxillary fixation due to multiple facial fractures. Which type of equipment should be at the client's bedside?
- A. Wire cutters
- B. NG tube
- C. Urinary catheter tray
- D. IV infusion pump
Correct Answer: A
Rationale: The correct answer is A: Wire cutters. In postoperative intermaxillary fixation, wire cutters are essential at the bedside in case of an emergency airway obstruction or need for immediate removal of the fixation. Wire cutters allow quick access to the airway without causing harm to the client.
B: NG tube is not necessary for postoperative intermaxillary fixation.
C: Urinary catheter tray is not directly related to the client's airway or fixation.
D: IV infusion pump is not specifically required for managing intermaxillary fixation emergencies.
In summary, wire cutters are crucial for ensuring client safety and airway management in postoperative intermaxillary fixation, making it the most appropriate equipment to have at the bedside.
Which nursing actions are completed by the scrub nurse (select all that apply)?
- A. Prepares instrument table
- B. Documents intraoperative care
- C. Remains in the sterile area of the OR
- D. Checks mechanical and electrical equipment
Correct Answer: A
Rationale: The scrub nurse manages sterile instruments and assists the surgical team within the sterile field.
Which assessment tools can be used to assess the cardiac system (select all that apply)?
- A. Watch
- B. Stethoscope
- C. Ophthalmoscope
- D. Percussion hammer
Correct Answer: D
Rationale: The correct answers are 'Watch,' 'Stethoscope,' 'Percussion hammer,' and 'Blood pressure cuff.' These tools aid in evaluating heart rate, rhythm, sounds, and vascular status.