Nokea
When preparing a site for venipunctures with alcohol, how long must the area be cleaned?
- A. 5 seconds
- B. 10 seconds
- C. 30 seconds
- D. 60 seconds
Correct Answer: C
Rationale: When preparing a site for venipunctures with alcohol, it is important to clean the area for at least 30 seconds. This ensures that the alcohol thoroughly disinfects the skin and reduces the risk of introducing infections during the procedure. Cleaning the area for a full 30 seconds allows the alcohol to effectively kill any bacteria present on the skin's surface, creating a safe environment for the venipuncture to take place. Shortening the cleaning time may compromise the cleanliness of the site and increase the chances of contamination. Therefore, 30 seconds is the recommended duration for cleaning the site with alcohol before a venipuncture.
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A patient with a brain tumor is admitted to the medical unit to begin radiation treatments. Which nursing action should take priority?
- A. Pad the patient's side rails
- B. Teach the patient what to expect during
- C. Assess the patient's pain level radiation treatments
- D. Place the patient in isolation
Correct Answer: C
Rationale: Assessing the patient's pain level should take priority in this situation because pain management is crucial for the comfort and well-being of the patient with a brain tumor undergoing radiation treatments. Pain can affect the patient's overall quality of life and participation in treatment. By promptly assessing the patient's pain level, the nurse can determine the need for appropriate pain management interventions to ensure the patient's comfort and enhance treatment outcomes. It is important to address the patient's pain to provide holistic care and improve the patient's overall experience during the treatment process.
Bell's palsy is a ___ cranial nerve disorder characterized by weakness or paralysis of the facial muscles.
- A. 3rd
- B. 7th
- C. 5th
- D. 8th
Correct Answer: B
Rationale: Bell's palsy is a cranial nerve disorder characterized by weakness or paralysis of the facial muscles due to inflammation, compression, or damage to the seventh cranial nerve - the facial nerve. The facial nerve controls the muscles responsible for facial expressions and functions like smiling, closing the eyes, and raising the eyebrows. Symptoms of Bell's palsy can include drooping of one side of the face, difficulty in closing one eye, drooling, impaired taste, and difficulty in smiling.
The following would be a symptom the nurse would expect to find during assessment of a patient with macular degeneration, EXCEPT:
- A. Decreased ability to distinguish colors
- B. Loss of central vision
- C. Loss of near vision
- D. Loss of peripheral vision
Correct Answer: D
Rationale: Macular degeneration primarily affects the macula, which is responsible for central vision. Therefore, symptoms typically include loss of central vision, decreased ability to distinguish colors, and loss of near vision. Loss of peripheral vision is not a common symptom associated with macular degeneration. Instead, it is more commonly seen in conditions affecting the peripheral retina, such as retinitis pigmentosa.
A chest radiograph film is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the radiograph show about the heart?" What knowledge about the x-ray should the nurse include in the response to the parents?
- A. Bones of chest but not the heart
- B. Measurement of electrical potential generated from heart muscle
- C. Permanent record of heart size and configuration
- D. Computerized image of heart vessels and tissues
Correct Answer: C
Rationale: A chest radiograph film, commonly known as a chest X-ray, shows a permanent record of the size and configuration of the heart. It can provide information about the overall size and shape of the heart, the presence of any abnormalities (such as an enlarged heart), and the position of the heart within the chest cavity. While a chest X-ray can also show the bones of the chest, it is primarily used to visualize the heart and lungs. It does not measure electrical potential generated from heart muscle (which would be seen on an ECG) or show a computerized image of heart vessels and tissues (which would typically require more advanced imaging techniques such as a CT scan or MRI).
Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The nurse should wake up a client who is to undergo an EEG at midnight to ensure that the client receives optimum sleep before the procedure. Optimum sleep helps regulate the client's breathing patterns during the EEG, resulting in more accurate readings. Adequate rest is essential for brain activity monitoring to be as normal as possible. Waking the client at midnight allows for enough time for the client to fall back asleep before the EEG is conducted, ensuring the best possible conditions for the procedure.