Nokea
Which of the following nursing intervention is needed before teaching a client post spleenectomy deep breathing and coughing exercises?
- A. Tell the patient that deep breathing and coughing exercises is needed to promote good breathing, circulation and prevent complication
- B. Tell the client that deep breathing and coughing exercises is needed to prevent Thrombophlebitis, hydrostatic pneumonia and atelectasis
- C. Medicate client for pain
- D. Tell client that cooperation is vital to improve recovery
Correct Answer: C
Rationale: Medicating for pain (C) is needed before teaching post-splenectomy exercises; pain hinders participation, per nursing care. General benefits (A), specific risks (B), and cooperation (D) follow pain control. C ensures effective learning, making it correct.
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Which of the following nursing intervention is appropriate when an IV infusion infiltrates?
- A. Elevate the site
- B. Discontinue the infusion
- C. Attempt to flush the tube
- D. Apply warm, moist compress
Correct Answer: B
Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.
Which of the following statement best describe collaboration in nursing?
- A. Working alone
- B. Working with others for care
- C. A competitive task
- D. A one-time event
Correct Answer: B
Rationale: Collaboration is working with others for care (B), per nursing e.g., team goals. Not alone (A), not competitive (C), not one-time (D) joint effort. B best defines collaboration's teamwork, making it correct.
When caring for a client receiving oxygen therapy, the nurse identifies condensation in the oxygen tubing. What action should the nurse take?
- A. Increase the oxygen flow rate to prevent condensation
- B. Disconnect the tubing and drain the condensation
- C. Replace the oxygen tubing with a new one immediately
- D. Place a heat-moisture exchanger (HME) on the oxygen tubing
Correct Answer: B
Rationale: Disconnecting and draining condensation (B) resolves impedance in oxygen flow from water buildup, maintaining effective delivery. Increasing flow (A) doesn't address it. Replacing tubing (C) is unnecessary if drained. HME (D) is for humidification, not condensation. Draining, per respiratory care, ensures uninterrupted therapy.
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.
An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
- A. Stiffness of the right ankle joint
- B. Soreness of the gums
- C. Short-term memory loss
- D. Decreased appetite
Correct Answer: A
Rationale: Joint stiffness signals early contractures or atrophy from immobility.