Nokea
Which member of the surgical team does not scrub in the OR?
- A. The surgeon.
- B. The circulating nurse.
- C. The scrub nurse or surgical tech.
- D. The holding area nurse.
Correct Answer: B
Rationale: The circulating nurse remains outside the sterile field to assist with supplies.
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Which of the following would have the highest priority in septic shock?
- A. Monitoring temperature.
- B. Monitoring pupillary reaction.
- C. Monitoring airway, breathing, circulation (ABC).
- D. Monitoring ANA and RF levels.
Correct Answer: C
Rationale: Maintaining ABCs is critical in septic shock.
To do an effective breast self-examination, when should the woman examine her breasts?
- A. During the fourth to the seventh menstrual cycle day
- B. Every other month
- C. While standing up
- D. 1 week before the menstrual cycle
Correct Answer: A
Rationale: The correct answer is A: During the fourth to the seventh menstrual cycle day. This is because breasts are least likely to be swollen or tender during this time, allowing for a more accurate examination. Choice B is incorrect as regular monthly examinations are recommended. Choice C can be done while standing up or lying down. Choice D is incorrect as breasts may be more tender and swollen closer to the menstrual cycle, making it harder to detect abnormalities.
When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing.
- B. Ask the RN to assess the vital signs.
- C. Measure the pulse oximetry.
- D. Continue to monitor respirations.
Correct Answer: C
Rationale: Pulse oximetry provides critical data on oxygenation.
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown:
- A. Ileostomy.
- B. Transverse colostomy.
- C. Ileal conduit.
- D. Sigmoid colostomy.
Correct Answer: A
Rationale: Ileostomies produce more caustic effluent, increasing skin irritation risk.
List and briefly describe the five dimensions of pain.
- A. Biological dimension: Physiological aspects of pain
- B. Behavioral dimension: Observable responses to pain
- C. Cognitive dimension: Thought processes related to pain
- D. Emotional dimension: Psychological reactions to pain
Correct Answer: A
Rationale: The correct answer includes all five dimensions: biological, behavioral, cognitive, emotional, and sociocultural.