Nokea
When caring for a client receiving oxygen therapy, the nurse identifies condensation in the oxygen tubing. What action should the nurse take?
- A. Increase the oxygen flow rate to prevent condensation
- B. Disconnect the tubing and drain the condensation
- C. Replace the oxygen tubing with a new one immediately
- D. Place a heat-moisture exchanger (HME) on the oxygen tubing
Correct Answer: B
Rationale: Disconnecting and draining condensation (B) resolves impedance in oxygen flow from water buildup, maintaining effective delivery. Increasing flow (A) doesn't address it. Replacing tubing (C) is unnecessary if drained. HME (D) is for humidification, not condensation. Draining, per respiratory care, ensures uninterrupted therapy.
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The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?
- A. 6
- B. 9
- C. 12
- D. 15
Correct Answer: A
Rationale: A Glasgow Coma Scale (GCS) score of 6 (A) indicates coma, defined as ≤8, reflecting minimal responsiveness (eye, verbal, motor). Scores of 9 (B) and 12 (C) suggest moderate injury. 15 (D) is normal. A is correct. Rationale: GCS ≤8 signifies severe brain dysfunction, often requiring intubation, a standard threshold in neurocritical care for coma classification and management.
Which psychological effect is commonly observed in patients experiencing immobility?
- A. Increased motivation
- B. Decreased risk of depression
- C. Increased sense of independence
- D. Increased risk of anxiety and depression
Correct Answer: D
Rationale: Immobility often increases anxiety and depression risk, as patients face mobility loss, dependence, and isolation, fostering psychological distress. Motivation and independence typically wane with restricted activity, while depression risk rises, not falls, due to these constraints. Nurses address this through emotional support and engagement, understanding that mental health declines when physical freedom is curtailed. This effect highlights the need for holistic care, blending physical interventions with psychological support to mitigate the emotional toll of immobility on patients.
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is difficulty breathing relieved by an upright position.
She dies of yellow fever in her search for truth to prove that yellow fever is carried by a mosquitoes.
- A. Clara louise Maas
- B. Pearl Tucker
- C. Isabel Hampton Robb
- D. Caroline Hampton Robb
Correct Answer: A
Rationale: Clara Louise Maas died in 1901 proving yellow fever's mosquito link volunteering for bites advancing epidemiology. Unlike Tucker, Robb (educator), or Hampton Robb (surgical pioneer), her sacrifice at 25 impacted public health, a heroic legacy in nursing research and disease prevention history.
When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:
- A. Protect the patient from injury
- B. Insert an airway
- C. Elevate the head of the bed
- D. Withdraw all pain medications
Correct Answer: A
Rationale: Protecting an unconscious patient from injury is the top priority.