Nokea
Which of the following is considered normal adult bladder capacity?
- A. 100-200 ml
- B. 400-500 ml
- C. 50-100 ml
- D. 800-1000 ml
Correct Answer: B
Rationale: Adult bladder capacity is 400-500 ml e.g., typical urge at 300-400. Less (50-200) or more (800-1000) don't fit. Nurses note e.g., catheter output for function, per physiology.
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A client has a mean arterial blood pressure (MAP) of $97 \mathrm{mmHg}$ and an intracranial pressure (ICP) of $12 \mathrm{mmHg}$. What is the cerebral perfusion pressure (CPP) for this client?
- A. 75
- B. 85
- C. 97
- D. 109
Correct Answer: B
Rationale: CPP = MAP - ICP; 97 - 12 = 85 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP measures brain perfusion; 85 mmHg is within normal (60-100 mmHg), critical for assessing adequacy post-injury, per neurocritical care formulas.
Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he is a human being. What major ingredient of a therapeutic communication is Nurse Aida using?
- A. Empathy
- B. Positive regard
- C. Comfortable sense of self
- D. Self awareness
Correct Answer: B
Rationale: Nurse Aida uses positive regard (B), valuing Roger as a human despite his behavior, a key therapeutic communication ingredient per Rogers. Empathy (A) involves feeling with the client, not just valuing them. Comfortable sense of self (C) is the nurse's confidence, and self-awareness (D) is understanding one's reactions. Positive regard fosters acceptance, crucial for trust and healing, aligning with Aida's stance, making B correct.
The nurse is preparing a client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to elevate the legs
- B. Walking long distances
- C. Sitting in a chair for long periods
- D. Sleeping in a flat position
Correct Answer: C
Rationale: Sitting in a chair for long periods post-axillopopliteal bypass risks kinking the graft or pooling blood, impairing circulation and healing a key discharge caution. Elevating legs, walking, or lying flat supports venous return and graft patency. Nurses teach this to prevent thrombosis or occlusion, ensuring clients maintain mobility and positioning to optimize surgical outcomes and limb perfusion.
The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: All are critical to monitor bleeding risks and heparin efficacy.
A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
- A. Writing down all assignments
- B. Making changes after evaluating the situation and having discussions with the staff
- C. Telling the staff nurses that she is making changes to benefit their performance
- D. Evaluating the clinical performance of each staff nurse in a private conference
Correct Answer: B
Rationale: Evaluating and discussing changes eases transition and builds trust.