Nokea
Which cranial nerve is responsible for the sense of smell?
- A. Olfactory nerve
- B. Optic nerve
- C. Trigeminal nerve
- D. Vagus nerve
Correct Answer: A
Rationale: The olfactory nerve (Cranial Nerve I) is indeed responsible for the sense of smell. It is located in the nasal cavity and transmits olfactory information to the brain. The optic nerve (Choice B) is responsible for vision, the trigeminal nerve (Choice C) is responsible for sensation in the face, and the vagus nerve (Choice D) is responsible for various functions such as heart rate, digestion, and speech. Therefore, the correct answer is the olfactory nerve (Choice A).
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A post-operative client develops a sudden onset of chest pain and dyspnea. The nurse suspects a pulmonary embolism (PE). What is the priority nursing action?
- A. Administer oxygen via face mask.
- B. Elevate the client's legs.
- C. Prepare the client for immediate surgery.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: Administering oxygen via face mask is the priority nursing action in a post-operative client suspected of a pulmonary embolism. This intervention helps ensure adequate oxygenation while further assessments and interventions are initiated. Elevating the client's legs is not indicated for a suspected pulmonary embolism; it is more appropriate for conditions like shock. Immediate surgery is not the priority in this situation as the client is experiencing acute symptoms requiring prompt intervention. While notifying the healthcare provider is important, the immediate focus should be on providing oxygen to the client to support respiratory function.
While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the nurse implement first?
- A. Administer sublingual nitroglycerin
- B. Assist the client back to the room
- C. Have the client sit down in the hall
- D. Obtain a 12-lead electrocardiogram
Correct Answer: C
Rationale: Having the client sit down in the hallway is the first action the nurse should implement. This is crucial to prevent further strain on the heart and to provide a safer environment for assessment and potential emergency intervention. Administering sublingual nitroglycerin (Choice A) may be appropriate later but should not precede ensuring the client's immediate safety. Assisting the client back to the room (Choice B) may not be advisable if the client is experiencing chest tightness and shortness of breath. Obtaining a 12-lead electrocardiogram (Choice D) is important but would not be the initial action to address the client's immediate symptoms.
The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP?
- A. Explain how to use a communication board
- B. Document progress in the use of the communication board
- C. Encourage voiding by assisting the client to the bedside commode
- D. Establish a bladder training schedule and methods
Correct Answer: C
Rationale: Assisting the client to the bedside commode is an appropriate task for the UAP as it involves basic patient care and mobility assistance, which are within the UAP's scope of practice. Options A and B involve communication techniques and documentation, which are more appropriate for licensed nursing staff. Option D involves establishing a bladder training schedule, which requires assessment and planning skills beyond the UAP's role.
Which electrolyte imbalance is most likely to cause cardiac arrhythmias?
- A. Hyperkalemia
- B. Hypocalcemia
- C. Hypernatremia
- D. Hypokalemia
Correct Answer: A
Rationale: Hyperkalemia is the correct answer as it can lead to dangerous cardiac arrhythmias due to its effects on the electrical conduction of the heart. High levels of potassium can disrupt the normal electrical activity of the heart, potentially leading to life-threatening arrhythmias. Hypocalcemia (choice B) is not the most likely cause of cardiac arrhythmias compared to hyperkalemia. Hypernatremia (choice C), referring to high sodium levels, is not directly associated with causing cardiac arrhythmias. While hypokalemia (choice D), low potassium levels, can also lead to cardiac arrhythmias, hyperkalemia is the more likely culprit in causing severe disturbances in heart rhythm.
According to the principle of asepsis, which situation should the PN consider to be sterile?
- A. A one-inch border around the edges of a sterile field set up in the operating room
- B. A sterile glove that the PN thinks might have touched hair
- C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp table top
- D. An open sterile Foley catheter kit set up on a table at the PN's waist level
Correct Answer: A
Rationale: According to the principle of asepsis, the one-inch border around the edges of a sterile field set up in the operating room is considered non-sterile, while the central area remains sterile. Therefore, the PN should consider the situation described in choice A to be sterile. Choice B is incorrect because a glove that may have touched hair is contaminated. Choice C is incorrect as a sterile item placed on a damp surface is considered contaminated. Choice D is incorrect as a sterile kit set up at the PN's waist level is prone to contamination.