Nokea
Which of the following is NOT true about post mortem care?
- A. The body should be placed in a morgue within 1 hour
- B. Wash hands before and after care
- C. Remove tubes and soiled linens
- D. Close the eyes and mouth
Correct Answer: A
Rationale: Body to morgue within 1 hour (A) isn't true no strict universal timing, per facility policy. Hand washing (B), tube removal (C), and closing eyes/mouth (D) are standard. A's rigidity misaligns with flexible care, making it untrue.
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In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?
- A. A Glasgow Coma Scale score of 13
- B. Clear fluid leaking from the nose
- C. Nausea and vomiting
- D. Anisocoria
Correct Answer: B
Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.
A client with peptic ulcer disease is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should avoid drinking milk.
- B. I should avoid drinking coffee.
- C. I should avoid eating high-fiber foods.
- D. I should avoid eating low-fat foods.
Correct Answer: B
Rationale: The correct answer is B. Avoiding coffee is important in managing peptic ulcer disease as it helps reduce acid production and alleviate symptoms. Coffee is known to stimulate acid secretion in the stomach, which can exacerbate ulcer symptoms. Therefore, instructing the client to avoid drinking coffee is essential in the dietary management of peptic ulcer disease. Choices A, C, and D are incorrect. Drinking milk is generally allowed and can even provide a protective effect against ulcers. High-fiber foods are beneficial for digestion and do not need to be avoided unless they cause discomfort. Low-fat foods are also typically recommended for individuals with peptic ulcer disease as they are easier on the digestive system.
The nurse ensured Mr. Gary's treatment wishes were followed. This is an example of?
- A. Advocacy
- B. Management
- C. Health literacy
- D. Quality improvement
Correct Answer: A
Rationale: Ensuring treatment wishes is advocacy (A) protecting rights, per definition. Management (B) organizes, literacy (C) understands, QI (D) enhances not rights-specific. A fits patient voice, making it correct.
Which of the following statement is NOT true about resilience?
- A. Can be developed
- B. Helps in stress management
- C. Always present at birth
- D. Affected by support systems
Correct Answer: C
Rationale: Resilience can develop (A), aids stress (B), affected by support (D) 'always present at birth' (C) isn't true, grows over time, per research. C's innate claim fails, making it untrue.
The nurse is providing care for a client with a chest tube. If the chest tube becomes disconnected from the drainage system, the nurse should:
- A. Secure the chest tube with tape and notify the physician
- B. Clamp the chest tube near the insertion site
- C. Submerge the end of the tube in sterile water
- D. Insert the tube into the drainage system without cleansing
Correct Answer: C
Rationale: Submerging the chest tube end in sterile water creates a water seal, preventing pneumothorax if disconnected taping delays, clamping risks tension pneumothorax, and reinserting uncleaned spreads infection. Nurses act quickly, ensuring lung re-expansion, critical in chest tube care.