Nokea
Which complications are related to anorexia nervosa?
- A. Premature wrinkles
- B. Vitamin excess
- C. Stress fractures in spine or hip
- D. Fluid overload
Correct Answer: C
Rationale: Severe weight loss weakens bones, increasing the risk of stress fractures in weight-bearing areas like the spine and hips.
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Which task is appropriate to delegate to the nursing assistant?
- A. Chest compressions
- B. Bag-valve mask ventilation
- C. Assisting with oral intubation
- D. Placing the defibrillator pads
Correct Answer: A
Rationale: Chest compressions are a physical task that can be delegated to a nursing assistant under supervision.
You are caring for a patient who has had a transurethral resection of the prostate for benign prostatic hypertrophy. There is continuous bladder irrigation setup. You would notify the physician if you noted
- A. Any signs of hematuria.
- B. A change from clear red output to thicker, bright red output.
- C. A decrease in the amount of blood in the urine.
- D. The development of uremic pruritis.
Correct Answer: B
Rationale: Thicker, bright red output indicates potential bleeding requiring medical attention.
How should the nurse position Mr. Jones’ chest drainage unit while he is transported?
- A. Below the chest level
- B. On the stretcher
- C. The unit should be removed
- D. The tubes should be clamped
Correct Answer: A
Rationale: The correct answer is A: Below the chest level. Positioning the chest drainage unit below the chest level allows for effective drainage of air or fluid from the chest cavity. Placing it above the chest level may cause backflow or air/fluid accumulation. Option B is incorrect as the unit should be secured to prevent dislodging during transport. Option C is incorrect as removing the unit can lead to complications. Option D is incorrect as clamping the tubes can result in a tension pneumothorax. Positioning the unit below the chest level ensures proper drainage and prevents complications during transport.
If a client denies having a hearing impairment, which question would encourage them to respond?
- A. Do you always ask people to repeat questions? If so, do you think that you have a hearing problem?
- B. Are you cupping your ear for a reason? Do you have trouble hearing?
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Asking open-ended questions increases the likelihood of acknowledgment and discussion of the issue.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider.
- B. Check vital signs.
- C. Position in high Fowler's.
- D. Administer oxygen.
Correct Answer: D
Rationale: Oxygen administration is immediate to address hypoxemia.