Nokea
Which of the following actions should the nurse take to maintain patient safety when ambulating a patient for the first time postoperatively?
- A. Use one person to assist patient.
- B. Use two people to assist patient.
- C. Encourage patient to "dangle" self 1 hour before ambulation.
- D. Give narcotic 15 minutes before ambulation.
Correct Answer: B
Rationale: When ambulating a patient for the first time postoperatively, it is crucial to ensure patient safety by using two people to assist the patient. This helps in providing adequate support and stability, especially if the patient is weak, dizzy, or at risk of falling. Having two people allows for better control over the patient's movement and reduces the risk of accidents or falls during ambulation. Additionally, having an extra person provides assistance in case the patient becomes unsteady or requires immediate support.
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How many liters per minute of oxygen should be administered to the patient with emphysema?
- A. 2 L/min
- B. 10 L/min
- C. 6 L/min
- D. 95 L/min
Correct Answer: C
Rationale: Oxygen therapy for patients with emphysema aims to maintain adequate oxygen levels in the blood while avoiding toxic levels of oxygen. The recommended flow rate for oxygen administration in patients with emphysema is typically 1-3 liters per minute. Increasing the flow rate above this range may lead to oxygen toxicity in these patients. Therefore, a safe and appropriate oxygen flow rate for a patient with emphysema would be around 6 L/min, making option C, 6 L/min, the correct choice from the provided options.
The most serious manifestation of lead intoxication is
- A. peripheral neuropathy
- B. mental retardation
- C. anemia
- D. cerebral edema
Correct Answer: D
Rationale: Cerebral edema is the most serious manifestation of lead intoxication, as it can be life-threatening.
Which of the ff vessels is often used for grafting?
- A. The basic and cephalic veins in the arm
- B. The internal mammary and internal thoracic arteries in the chest
- C. The saphenous vein in the leg
- D. The radial artery in the arm
Correct Answer: B
Rationale: The internal mammary and internal thoracic arteries in the chest are often used for grafting in procedures such as coronary artery bypass surgery. These arteries have been found to have good long-term patency rates when used as grafts to bypass blocked coronary arteries. The internal mammary artery, in particular, is commonly used for this purpose due to its accessibility and long-term durability. The use of these arteries for grafting helps to improve blood flow to the heart muscle, relieving symptoms of coronary artery disease and reducing the risk of heart-related complications.
The nurse has been caring for a newborn who just died. The parents are present but say they are "afraid" to hold the dead newborn. Which is the most appropriate nursing intervention?
- A. Tell them there is nothing to fear.
- B. Insist that they hold newborn "one last time."
- C. Respect their wishes and release body to morgue.
- D. Keep newborn's body available for a few hours in case they change their minds.
Correct Answer: D
Rationale: The most appropriate nursing intervention in this situation is to keep the newborn's body available for a few hours in case the parents change their minds. It is important to respect the parents' feelings and fears while also providing them with the opportunity to hold their child if they decide to do so later on. By keeping the newborn's body available, the parents can have the time and space they need to process their emotions and make a decision that feels right for them. This approach supports the parents' autonomy and allows them to grieve in a way that is meaningful to them.
Which of the following is the appropriate nursing diagnosis?
- A. Fluid volume deficit R/T furrow tongue
- B. Fluid volume deficit R/T uncontrolled vomiting
- C. Dehydration R/T subnormal body temperature
- D. Dehydration R/T incessant vomiting
Correct Answer: B
Rationale: The appropriate nursing diagnosis is Fluid volume deficit R/T uncontrolled vomiting. This diagnosis is the most specific and directly related to the issue of vomiting causing a loss of fluids, leading to a deficit in fluid volume. Uncontrolled vomiting can result in a significant loss of fluids and electrolytes, which can lead to dehydration. It is important to address the root cause of the fluid volume deficit, which in this case is the uncontrolled vomiting. The other options may not directly address the primary issue of fluid loss due to vomiting.