Nokea
Which of the following is NOT true about BP?
- A. BP is dependent on blood volume, Cardiac output and peripheral resistance
- B. BP is dependent on age and body weight
- C. The BP on the left arm is higher than the right
- D. BP is taken on the left arm because it is nearest to the heart
Correct Answer: C
Rationale: BP depends on blood volume, cardiac output, and peripheral resistance (A), and varies with age and weight (B), per cardiovascular physiology. The left arm isn't inherently higher (C) it's false; differences are minimal and individual. Left arm use (D) is convention, not proximity (it's not significantly closer). C's absolute claim lacks evidence, making it the untrue statement, as BP symmetry is typical unless pathology exists.
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Which of the following statement best describe autonomy?
- A. Doing good for the client
- B. Fairness and equality
- C. Respecting client's decision
- D. Keeping promises
Correct Answer: C
Rationale: Autonomy is respecting client decisions (C), per ethics self-determination (e.g., refusing care). Doing good (A) is beneficence, fairness (B) justice, promises (D) fidelity. C best defines autonomy's focus, making it correct.
The nurse is teaching a client who underwent a hypophysectomy for hypopituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.
- A. Nose blowing
- B. Teeth brushing
- C. Bending forward
- D. Lying in a semi-Fowler's position
Correct Answer: A
Rationale: Post-hypophysectomy, nose blowing (A) risks CSF leak or meningitis by disrupting the surgical site. Brushing (B) and semi-Fowler's (D) are safe. Bending (C) is risky but less immediate. A is correct. Rationale: Nasal pressure can breach the pituitary fossa repair, a critical complication in early recovery, per post-operative neurosurgery care, unlike benign actions.
Anaphylactic reaction after administering penicillin indicates
- A. An acquired atopic sensitization
- B. Passive immunity to penicillin allergen
- C. Antibodies to penicillin developed after earlier use of the drug
- D. Developed potent bivalent antibodies when the IV administration was started
Correct Answer: C
Rationale: Anaphylaxis is a severe IgE-mediated allergic reaction, occurring when prior penicillin exposure sensitizes the immune system, forming antibodies. Re-exposure triggers histamine release, causing symptoms like shock or dyspnea. Atopic sensitization relates to predisposition, not specific drug history. Passive immunity involves transferred antibodies, not self-developed ones. Bivalent antibodies forming during IV use is incorrect sensitization precedes administration. Nurses must assess allergy history, preparing for emergencies like epinephrine administration to reverse this life-threatening response.
The best diet for the client with Meniere's syndrome is one that is:
- A. High in fiber
- B. Low in sodium
- C. High in iodine
- D. Low in fiber
Correct Answer: B
Rationale: A low-sodium diet is best for Meniere's syndrome, reducing fluid retention in the inner ear, which mitigates vertigo, tinnitus, and hearing loss flare-ups. High fiber aids digestion, not ear issues; high iodine or low fiber lacks relevance here. Nurses teach this dietary shift to control symptoms, emphasizing sodium's role in fluid balance, supporting long-term management of this chronic condition.
The nurse is caring for a client following a right total hip replacement. Which action by the nurse will help prevent dislocation of the prosthesis?
- A. Keeping the client's knees together at all times
- B. Placing the client in a supine position with the legs extended
- C. Placing a pillow between the client's legs when turning
- D. Encouraging the client to use the trapeze to pull himself up in bed
Correct Answer: C
Rationale: Placing a pillow between the legs during turning maintains abduction, preventing hip prosthesis dislocation post-right total hip replacement knees together adducts, supine extension risks posterior dislocation, and trapeze use is safe but unrelated. Nurses enforce this, ensuring joint stability, key for orthopedic recovery.