Nokea
Which of the ff. nursing actions prepares a patient for a lumbar puncture?
- A. Administering enemas until clear
- B. Positioning the patient on his or her side
- C. Removing all metal jewelry
- D. Removing the patient’s dentures
Correct Answer: B
Rationale: The correct answer is B: Positioning the patient on his or her side. This is essential for a lumbar puncture as it helps to open up the spinal spaces, making it easier and safer for the procedure. Positioning the patient on their side also helps prevent complications such as nerve damage or spinal fluid leakage.
A: Administering enemas until clear is unnecessary and not directly related to preparing a patient for a lumbar puncture.
C: Removing all metal jewelry is important to prevent interference with imaging studies, but it is not directly related to preparing for a lumbar puncture.
D: Removing the patient’s dentures is not specifically required for a lumbar puncture procedure.
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A nurse changes a client’s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?
- A. Independent intervention
- B. Dependent intervention
- C. Interdependent intervention
- D. Collaborative intervention
Correct Answer: C
Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client.
Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.
Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that:
- A. Upper extremities are paralyzed
- B. Both lower and upper extremities are
- C. Lower extremities are paralyzed paralyzed
- D. One side of the body is paralyzed
Correct Answer: C
Rationale: Rationale:
- Paraplegia refers to paralysis of the lower extremities.
- The prefix "para-" means alongside or beside, indicating lower body involvement.
- Option A is incorrect as it refers to quadriplegia.
- Option B is incorrect as it refers to quadriplegia.
- Option D is incorrect as it refers to hemiplegia.
The normal range of hemoglobin in the blood of an adult:
- A. 7-11 mg
- B. 14-20 mg
- C. 12-18 mg
- D. 20-26 mg
Correct Answer: C
Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.
Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
- A. 10% dextrose and saline
- B. 5% dextrose and water
- C. 5% dextrose and water with 60 mEq
- D. Distilled water KCl
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
- A. Infusing IV fluids rapidly as ordered
- B. Administering glucose-containing IV
- C. Encouraging increased oral intake fluids as ordered
- D. Restricting fluids
Correct Answer: D
Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.