Nokea
Which of the following nursing intervention is appropriate to prevent pulmonary embolus in a patient who is prescribed bed rest?
- A. Limit the client's fluid intake
- B. Encourage deep breathing and coughing
- C. Use the knee gatch when the client is in bed
- D. Teach the patient to move legs in bed
Correct Answer: D
Rationale: Bed rest risks venous stasis, a pulmonary embolus cause. Leg movement promotes circulation, preventing clots from forming and traveling to lungs. Fluid limits dehydration but not emboli directly, deep breathing aids lungs but not veins, and knee gatch increases stasis. Nurses teach exercises, reducing thromboembolism risk, enhancing recovery safety.
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You are about to write an information on the Kardex. There are 4 available writing instruments to use. Which of the following should you use?
- A. Mongol #2
- B. Permanent Ink
- C. A felt or fountain pen
- D. Pilot Pentel Pen marker
Correct Answer: B
Rationale: Permanent ink (B) is required for Kardex to ensure legible, lasting records, per legal standards. Pencil (A) erases, felt/fountain pens (C) smudge, markers (D) fade. B ensures accuracy, making it correct.
The nurse administers cleansing enema. The common position for this procedure is...
- A. Sims left lateral
- B. Dorsal Recumbent
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sims left lateral allows easy access to the rectum and comfort during an enema.
A client who recently underwent a coronary artery bypass graft is taking furosemide and metoprolol following the procedure. While developing a plan for a heart-healthy diet with the nurse, the client states that diet did not contribute to the heart disease and that the client should be fine just continuing to take the medications. According to the Stages of Change Model, which stage of change is the client in related to diet?
- A. Precontemplation
- B. Contemplation
- C. Preparation
- D. Maintenance
Correct Answer: A
Rationale: The Stages of Change Model tracks behavior shift, and this client's denial of diet's role in heart disease places them in precontemplation. Here, individuals show no intent to change within six months, often resisting evidence like diet's link to atherosclerosis clinging to beliefs that meds alone suffice. Contemplation involves considering change, preparation plans it, and maintenance sustains it none apply, as the client isn't pondering dietary shifts. This stage reflects unawareness or defiance, common post-surgery when focusing on recovery, not prevention. Nursing must gently challenge this, using education like explaining sodium's impact on heart strain to nudge awareness, critical for moving them toward contemplation and eventual heart-healthy habits, preventing further cardiac issues.
Which of the following statement is NOT true about pulse pressure?
- A. Pulse pressure is the difference between the systolic and diastolic pressure
- B. Normal pulse pressure is 40 mmHg
- C. Pulse pressure increases when the systolic pressure is elevated and the diastolic pressure remains the same
- D. Elderly people have decreased pulse pressure due to loss of elasticity in the blood vessels
Correct Answer: D
Rationale: Pulse pressure is systolic minus diastolic (A), typically 40 mmHg (B), and rises if systolic increases with stable diastolic (C), per cardiovascular norms. Elderly have increased pulse pressure (D) due to arterial stiffness systolic rises, diastolic may drop making D untrue. Aging widens pulse pressure, not narrows it, contradicting D, thus it's the correct answer as the false statement.
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.