Nokea
Which of the following patients is at greatest risk for developing pressure ulcers?
- A. An alert chronic arthritic patient treated with steroids and aspirin
- B. An 88-year-old incontinent patient with gastric cancer who is confined to bed at home
- C. An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
- D. A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed
Correct Answer: B
Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.
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Which action would break sterile technique while preparing a sterile field for a dressing change?
- A. Using sterile forceps instead of sterile gloves to handle a sterile item
- B. Touching the outside wrapper of sterilized material without sterile gloves
- C. Placing a sterile object at the edge of the sterile field
- D. Pouring out a small amount of solution (15 to 30 ml) before pouring it into a sterile container
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the correct sequence for assessing the abdomen?
- A. Tympanic percussion, measurement of abdominal girth, and inspection
- B. Assessment for distention, tenderness, and discoloration around the umbilicus
- C. Percussion, palpation, and auscultation
- D. Auscultation, percussion, and palpation
Correct Answer: D
Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.
When is the most appropriate time for obtaining a sputum specimen for culture?
- A. Early in the morning
- B. After the patient eats a light breakfast
- C. After aerosol therapy
- D. After chest physiotherapy
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Examples of patients suffering from impaired awareness include all of the following except:
- A. A semiconscious or overfatigued patient
- B. A disoriented or confused patient
- C. A patient who cannot care for themselves at home
- D. A patient demonstrating symptoms of drug or alcohol withdrawal
Correct Answer: C
Rationale: Patients with impaired awareness may exhibit symptoms such as being semiconscious, overfatigued, disoriented, confused, or demonstrating symptoms of drug or alcohol withdrawal. A patient who cannot care for themselves at home does not necessarily indicate impaired awareness, as this could be due to physical limitations or lack of support, rather than a cognitive deficit.
When removing a contaminated gown, what should be the first thing touched by the nurse?
- A. Waist tie and neck tie at the back of the gown
- B. Waist tie in front of the gown
- C. Cuffs of the gown
- D. Inside of the gown
Correct Answer: A
Rationale: When removing a contaminated gown, the nurse should ensure the first thing touched is the waist tie and neck tie at the back of the gown. This procedure helps prevent contamination by ensuring that the outer surface of the gown, which is likely to be contaminated, is not touched during removal. By touching the back ties first, the nurse minimizes the risk of transferring any contaminants to themselves or the environment.