Nokea
Which of the following helps the nurse to identify goals, tailor the teaching plan, and evaluate outcomes?
- A. Desire to acquire new information.
- B. Assessment of what the client knows.
- C. Purpose or reason for mastering skills.
- D. Restored independence.
Correct Answer: B
Rationale: Assessing the client's existing knowledge provides a foundation for setting realistic goals and tailoring the teaching plan.
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End-of-life palliative nursing care involves
- A. Constant assessment for changes in physiologic functioning.
- B. Administering large doses of analgesics to keep the patient sedated.
- C. Providing as little physical care as possible to prevent disturbing the patient.
- D. Encouraging the patient and family members to verbalize their feelings of sadness
Correct Answer: D
Rationale: Emotional and psychological support for both the patient and family is crucial in palliative care, helping them process feelings and find closure.
A healthcare provider is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the provider place at the client's bedside?
- A. Bag valve mask device
- B. Defibrillator machine
- C. Chest tube equipment
- D. Central venous catheter tray
Correct Answer: A
Rationale: The correct answer is A: Bag valve mask device. In the PACU, a client who received a competitive neuromuscular blocking agent may have impaired respiratory function. Placing a bag valve mask device at the bedside is crucial for providing immediate respiratory support if needed. This device allows manual ventilation in case of respiratory distress.
Summary:
- Choice B: Defibrillator machine is not necessary for a client receiving a competitive neuromuscular blocking agent.
- Choice C: Chest tube equipment is not typically needed for this situation.
- Choice D: Central venous catheter tray is not directly related to the respiratory support required for a client with impaired respiratory function.
Mary asks how the pulmonary function test ordered by her physician is performed. You respond by saying
- A. You breathe into a spirometer to measure your lung capacity.
- B. You breathe through a mouthpiece into a spirometer until all air in your lungs is expelled; then you take a deep breath through the mouthpiece. This is done three times and a computer calculates the capacity of your lungs.
- C. A computer is used to measure your volume and vital capacity.
- D. A tube is inserted into your lungs while you are asleep to expand your lungs to their full capacity.
Correct Answer: B
Rationale: Pulmonary function tests measure lung capacity using spirometry.
What symptoms would a nurse suspect in a client with acoustic neuroma?
- A. Altered facial sensation
- B. Vertigo only when standing
- C. Tinnitus in the unaffected ear
- D. Impaired facial movement when smiling
Correct Answer: A
Rationale: Acoustic neuromas often affect cranial nerve VII, leading to altered facial sensation.
To communicate with a patient who does not speak the dominant language, the nurse should
- A. Speak slowly and enunciate clearly in a slightly louder voice.
- B. Use gestures and pantomime words while verbalizing specific words.
- C. Use family members rather than strangers as interpreters to increase the patient’s feeling of comfort.
- D. Use a dictionary or phrase books that translate from both the nurse’s language and the patient’s language.
Correct Answer: A
Rationale: Speaking slowly, using gestures, and utilizing translation tools facilitate effective communication. Using family members as interpreters can introduce bias and inaccuracies.