Which of the following conditions may necessitate fluid restriction?
- A. Fever
- B. Chronic Obstructive Pulmonary Disease
- C. Renal Failure
- D. Dehydration
Correct Answer: C
Rationale: Renal failure often necessitates fluid restriction to prevent fluid overload. In renal failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to fluid accumulation in the body. Restricting fluid intake helps manage this condition by preventing further fluid buildup and complications such as edema and electrolyte imbalances.
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Which of the following procedures always requires surgical asepsis?
- A. Vaginal instillation of conjugated estrogen
- B. Urinary catheterization
- C. Nasogastric tube insertion
- D. Colostomy irrigation
Correct Answer: B
Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.
A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct Answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
What is required for effective hand washing?
- A. Soap or detergent to promote emulsification
- B. Hot water to destroy bacteria
- C. A disinfectant to increase surface tension
- D. All of the above
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In Maslow's hierarchy of physiological needs, the human need of greatest priority is:
- A. Love
- B. Elimination
- C. Nutrition
- D. Oxygen
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?
- A. Opening the patient's window to the outside environment
- B. Turning on the patient's room ventilator
- C. Opening the door of the patient's room leading into the hospital corridor
- D. Failing to wear gloves when administering a bed bath
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.