Nokea
When teaching a 69-year-old patient about self-care, what will promote health (select all that apply)?
- A. Proper diet
- B. Immunizations
- C. Teaching chair yoga
- D. Demonstrating balancing techniques
Correct Answer: D
Rationale: Healthy eating, vaccinations, physical activity (including chair yoga), and balance training enhance overall well-being and independence in older adults.
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Which drainage is drained with a Hemovac?
- A. Bile
- B. Urine
- C. Gastric contents
- D. Wound drainage
Correct Answer: D
Rationale: Hemovacs are used for wound drainage, collecting serosanguinous fluid.
In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?
- A. Airway protection
- B. Decreasing intracranial pressure
- C. Stabilizing cardiac arrhythmias
- D. Preventing musculoskeletal disability
Correct Answer: A
Rationale: The correct answer is A: Airway protection. The priority focus of care in a client with multiple system trauma is to ensure a patent airway to maintain oxygenation and ventilation. Without a clear airway, the client can rapidly deteriorate. Airway management takes precedence over other interventions to prevent hypoxia and respiratory failure. Decreasing intracranial pressure (B) and stabilizing cardiac arrhythmias (C) are important but secondary to ensuring adequate oxygenation. Preventing musculoskeletal disability (D) is not the immediate concern in this critical situation.
What should be included in Mr. Dean’s teaching plan for respiratory isolation?
- A. Using disposable tissues for his respiratory secretions
- B. Reporting any allergies to the staff
- C. Asking family and friends not to visit
- D. Getting the patient out of bed frequently
Correct Answer: A
Rationale: Disposable tissues prevent the spread of pathogens.
What assessment data will the nurse gather when caring for a client with anxiety?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
- A. Provide high-flow oxygen.
- B. Check the client for a positive Chvostek's sign.
- C. Administer an IV vasopressor medication.
- D. Monitor the client for headache.
Correct Answer: A
Rationale: Step 1: Recognize potential complications of femur fracture - fat embolism syndrome (FES) can cause sudden onset dyspnea and chest pain.
Step 2: Provide high-flow oxygen to improve oxygenation and stabilize the client's condition.
Step 3: Oxygen therapy takes priority to address potential respiratory compromise and prevent further deterioration.
Summary:
- Option B (Chvostek's sign) is unrelated to the client's current symptoms.
- Option C (IV vasopressor) is not indicated for FES.
- Option D (monitor for headache) is not a priority when the client is experiencing dyspnea and chest pain.