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.
You may also like to solve these questions
While planning nursing process for a patient who is at risk for suicide, which of the following is the priority area for providing care :
- A. Sleep
- B. Nutrition
- C. Self-esteem
- D. Safety
Correct Answer: D
Rationale: Suicide risk demands a prioritized nursing approach under the nursing process. Sleep (choice A) and nutrition (choice B) are basic needs, but disruptions are secondary to immediate risk. Self-esteem (choice C) influences mental health, yet addressing it is a longer-term goal. Safety (choice D) is the priority, as suicidal ideation poses an acute threat to life, requiring immediate interventions like removing hazards, constant observation, and risk assessment (e.g., SAD PERSONS scale). D is correct because ensuring safety prevents harm, the first step in stabilizing the patient. Nurses must implement safety protocols, collaborate with psychiatry, and then address sleep, nutrition, and esteem, building a comprehensive care plan.
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.
The nurse reported Mr. Gary's fall to improve safety. This is an example of?
- A. Incident reporting
- B. Documentation
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Reporting a fall is incident reporting (A) adverse event log, per definition. Documentation (B) records, promotion (C) well-being, transition (D) moves not report-specific. A fits the nurse's action for Mr. Gary's safety, making it correct.
All of the following are purpose of inflammation except
- A. Increase heat, thereby produce abatement of phagocytosis
- B. Localized tissue injury by increasing capillary permeability
- C. Protect the issue from injury by producing pain
- D. Prepare for tissue repair
Correct Answer: A
Rationale: Inflammation aims to protect and heal tissue, not hinder it. Increasing heat (A) enhances phagocytosis by boosting immune cell activity, not abating it, making this statement incorrect and the exception. Localized injury response (B) occurs as capillary permeability increases, delivering immune cells to the site. Pain (C) protects by discouraging movement, aiding healing. Preparing for tissue repair (D) is a key goal as inflammation clears debris and initiates recovery. The misstatement in A reverses the biological role of heat, which supports immune function rather than suppressing it, confirming A as the answer since it does not align with inflammation's purposes.
Which of the following statement best describe disability?
- A. Temporary loss of function
- B. Permanent loss of function
- C. Absence of disease
- D. A state of well being
Correct Answer: B
Rationale: Disability is permanent loss of function (B), per definition e.g., amputation impact. Temporary (A) is impairment, absence (C) health, well-being (D) opposite. B best defines disability's chronicity, making it correct.