Nokea
Which of the following is more life threatening?
- A. BP=180/100
- B. BP=160/120
- C. BP=90/60
- D. BP=80/50
Correct Answer: D
Rationale: BP 80/50 is most life-threatening e.g., hypoperfusion risks failure vs. 180/100 (hypertension), 160/120 (severe), 90/60 (borderline). Nurses prioritize this e.g., fluids for stability, per hemodynamics.
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A client with chronic obstructive pulmonary disease (COPD) is prescribed long-term oxygen therapy. What is the most important nursing consideration for this client?
- A. Assessing for signs of oxygen toxicity
- B. Monitoring the client's carbon dioxide levels
- C. Promoting proper humidification of oxygen
- D. Ensuring an adequate supply of oxygen
Correct Answer: B
Rationale: Monitoring carbon dioxide levels (B) is critical in COPD clients on long-term oxygen therapy, as they may retain CO2, risking respiratory acidosis if oxygen suppresses their hypoxic drive (target SpO2 88-92%). Oxygen toxicity (A) is rare at low flows used in COPD. Humidification (C) enhances comfort but isn't the priority. Oxygen supply (D) is a general need, not COPD-specific. CO2 monitoring via ABGs or capnography ensures safe titration, preventing hypercapnia, a key consideration per COPD management guidelines like GOLD standards.
A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
- A. Supine with head turned to the right
- B. Prone with the head straight
- C. Semi-Fowler's at 30 degrees
- D. High Fowler's at 90 degrees
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
1 cup is equal to how many ounces?
- A. 8
- B. 80
- C. 800
- D. 8000
Correct Answer: A
Rationale: One cup is standardized as 8 fluid ounces.
Which psychological effect is commonly observed in patients experiencing immobility?
- A. Increased motivation
- B. Decreased risk of depression
- C. Increased sense of independence
- D. Increased risk of anxiety and depression
Correct Answer: D
Rationale: Immobility often increases anxiety and depression risk, as patients face mobility loss, dependence, and isolation, fostering psychological distress. Motivation and independence typically wane with restricted activity, while depression risk rises, not falls, due to these constraints. Nurses address this through emotional support and engagement, understanding that mental health declines when physical freedom is curtailed. This effect highlights the need for holistic care, blending physical interventions with psychological support to mitigate the emotional toll of immobility on patients.
A community health nurse is assessing client's urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?
- A. The nurse added the Urine as the 2/3 part of the solution
- B. The nurse heats the test tube after adding 1/3 part acetic acid
- C. The nurse heats the test tube after adding 2/3 part of Urine
- D. The nurse determines abnormal result if she noticed that the test tube becomes cloudy
Correct Answer: B
Rationale: Acetic acid tests protein cloudiness not glucose; heating only acid (no urine) is wrong. Urine (2/3), heating with urine, cloudiness (protein) are correct. Nurses need correction e.g., purpose for accuracy, per procedure.