Nokea
Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?
- A. Have the patient place the specimen in a container and enclose the container in a plastic bag
- B. Have the patient expectorate the sputum while the nurse holds the container
- C. Have the patient expectorate the sputum into a sterile container
- D. Offer the patient an antiseptic mouthwash just before he expectorates the sputum
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Your assigned client has encephalitis, and there are other cases in the community. In a team meeting regarding your client and prevention of other cases of encephalitis, the nurse supervisor talks about breaking the chain of infection at the second link: the reservoir. You realize the nurse supervisor is talking about which of the following things?
- A. an area for the storage and filtering of water
- B. a place where the microorganism enters the body
- C. the place where the microorganism naturally lives
- D. the microorganism itself
Correct Answer: C
Rationale: Breaking the infection chain at the reservoir means targeting where the microorganism naturally lives like mosquitoes for encephalitis. This differs from the pathogen itself, entry portals, or unrelated water storage. Controlling reservoirs, such as vector elimination, stops transmission early, a vital nursing strategy in outbreak prevention discussed in team settings.
Which position should the nurse use for a patient who is immobile to promote lung expansion and prevent respiratory complications?
- A. Supine position with the head of the bed elevated
- B. Prone position with the head turned to the side
- C. Lateral position with the affected side down
- D. Semi-Fowler's position with the knees slightly flexed
Correct Answer: D
Rationale: Semi-Fowler's position with knees flexed promotes lung expansion in immobile patients by easing diaphragm movement, reducing respiratory complication risks like pneumonia. Supine restricts breathing, prone is impractical, and lateral may compress lungs. Nurses adopt this to optimize oxygenation, supporting recovery and comfort in those unable to shift positions independently.
Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
- A. Side rails are ineffective
- B. Side rails should not be used
- C. Side rails are a deterrent that prevent a patient from falling out of bed
- D. Side rails are a reminder to a patient not to get out of bed
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following Nursing diagnosis is INCORRECT?
- A. Fluid volume deficit R/T Diarrhea
- B. High risk for injury R/T Absence of side rails
- C. Possible ineffective coping R/T Loss of loved one
- D. Self esteem disturbance R/T Effects of surgical removal of the leg
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has a new prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take?
- A. Obtain a random blood glucose daily.
- B. Change the IV tubing every 72 hours.
- C. Apply a new dressing to the IV site every 24 hours.
- D. Weigh the client weekly.
Correct Answer: A
Rationale: When a client is on total parenteral nutrition (TPN), monitoring blood glucose levels daily is crucial to manage and detect complications like hyperglycemia, which can occur due to the high glucose content in TPN solutions. Regular blood glucose monitoring helps the healthcare team adjust the TPN infusion rate to maintain optimal glucose levels and prevent adverse events.