Nokea
Which infection control measure should Nurse Emma observe during her visit to the family.
- A. Wear mask
- B. Use face shield
- C. Use gloves
- D. Wear gown
Correct Answer: A
Rationale: Wearing a mask is an essential infection control measure to prevent the spread of respiratory illnesses, including COVID-19. By wearing a mask, Nurse Emma can reduce the risk of inhaling or exhaling respiratory droplets that may contain infectious particles, thus helping to protect herself and the family members she is visiting. Masks are particularly crucial when interacting with individuals who are sick or when physical distancing may be challenging. While using gloves, face shields, and gowns are also important infection control measures in certain situations, wearing a mask is the most relevant and effective measure during a home visit to prevent respiratory transmission of infections.
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A patient with a history of stroke is at risk for impaired skin integrity due to immobility. Which nursing intervention is most effective in preventing pressure ulcers in this patient?
- A. Turning and repositioning the patient every 2 hours
- B. Massaging bony prominences regularly
- C. Applying heating pads to areas of erythema
- D. Using a pressure-reducing mattress
Correct Answer: A
Rationale: Turning and repositioning the patient every 2 hours is the most effective nursing intervention in preventing pressure ulcers in a patient with a history of stroke and immobility. Pressure ulcers, also known as bedsores, are caused by prolonged pressure on the skin, leading to reduced blood flow and tissue damage. By regularly turning and repositioning the patient, pressure is relieved from specific areas of the body, helping to prevent the development of pressure ulcers. This intervention helps to redistribute pressure, improve blood flow, and reduce the risk of skin breakdown, thus promoting skin integrity in immobile patients.
After tracheostomy procedure, the nurse documents important observation made during the procedure such us _________.
- A. Response of the patient's after procedure
- B. Vital signs of the patient's during the procedure
- C. Amount, color and consistency of sputum and appearance of the incision
- D. Behavior of the patient during the procedure
Correct Answer: C
Rationale: It is essential for the nurse to document important observations made during a tracheostomy procedure, and this includes the amount, color, and consistency of sputum as well as the appearance of the incision. Monitoring these factors helps assess the patient's respiratory status, risk of infection, and wound healing progress. Ensuring detailed documentation in this area allows for timely intervention if there are any concerning changes observed post-procedure. Observations such as the response of the patient, vital signs during the procedure, and patient behavior are also important but may be documented separately from the specific details related to sputum, incision appearance, and wound care.
Some common examples of screening tests are the following, EXCEPT ________.
- A. Pap smears for cervical cancer screening in women.
- B. Cholesterol levels in heart disease screening.
- C. PSA levels for prostate CA in men.
- D. Urinalysis for male and female clients.
Correct Answer: D
Rationale: While urinalysis can provide valuable information about a person's health status and can be part of a clinical assessment, it is not typically considered a common screening test for specific diseases or conditions. The other options listed - Pap smears for cervical cancer screening, cholesterol levels for heart disease screening, and PSA levels for prostate cancer screening - are all commonly used screening tests aimed at early detection of specific diseases. Urinalysis is more commonly used as part of a broader health assessment or diagnostic evaluation rather than a dedicated screening tool for a specific condition.
The physician prescribes a treatment plan for patient Mila. Nurse Victor understands that the initial treatment goal is which of the following?
- A. Prevent infection
- B. Correct hypoxia
- C. Correct metabolic acidosis
- D. Increase myocardial oxygen supply
Correct Answer: A
Rationale: The initial treatment goal for a patient like Mila is often focused on preventing infection. Infection prevention is a basic and essential step in patient care, especially for someone who may be at risk due to their medical condition or treatment plan. By preventing infection, healthcare providers can help ensure the patient's safety and promote successful outcomes for the overall treatment plan. Correcting hypoxia, metabolic acidosis, and increasing myocardial oxygen supply may be important goals as well, but preventing infection is usually prioritized as it can have serious consequences if not addressed promptly.
Right after endorsement and during the rounds, the incoming nurse observes that the IV fluid is at 800 cc level and not 400cc, as endorsed. What is the CORRECT information that she will chart?
- A. Anything goes, nobody reads the charting anyway.
- B. Record the 400 cc.
- C. Chart that she received 800
- D. Refer to the Head Nurse on what to do.
Correct Answer: C
Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.