Nokea
Which of the following statement is TRUE about livor mortis?
- A. Cooling of the body after death
- B. Stiffening of the body after death
- C. Blood pooling on the dependent part of the body
- D. Shrinking of the body due to loss of fluid
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A healthcare professional is preparing to administer a subcutaneous injection. Which of the following actions should the healthcare professional take?
- A. Use a 1-inch needle.
- B. Insert the needle at a 90-degree angle.
- C. Use a tuberculin syringe.
- D. Aspirate before injecting.
Correct Answer: B
Rationale: When administering a subcutaneous injection, it is important to insert the needle at a 90-degree angle to ensure proper medication delivery into the subcutaneous tissue. This angle helps prevent the medication from being injected too deeply or too superficially, ensuring optimal absorption and therapeutic effect.
A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?
- A. Monitor intake and output every 8 hours.
- B. Flush the feeding tube every 4 hours.
- C. Measure the client's temperature every 24 hours.
- D. Change the feeding bag and tubing every 72 hours.
Correct Answer: B
Rationale: Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. Monitoring intake and output, measuring temperature, and changing the feeding bag and tubing are also important aspects of care but not directly related to maintaining the patency of the feeding tube in a client receiving continuous enteral feedings.
While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Increased skin turgor
- C. Dry mucous membranes
- D. Hypertension
Correct Answer: C
Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, and hypertension is not a typical finding in fluid volume deficit.
The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary level prevention?
- A. Screening for early detection
- B. Teaching about adhering to a low-sodium diet
- C. Promoting health before diagnosis
- D. Detecting disease early
Correct Answer: B
Rationale: Tertiary prevention occurs post-diagnosis, aiming to reduce disability and optimize function, as with this heart failure client. Teaching about a low-sodium diet helps manage symptoms reducing fluid retention, easing heart strain preventing readmissions by enhancing self-care after treatment. Screening or early detection aligns with secondary prevention, identifying issues before symptoms escalate. Promoting health pre-diagnosis is primary prevention, averting illness onset. Here, the nurse targets rehabilitation, addressing an established condition to minimize complications like edema, common in heart failure's chronic cycle. This education empowers the client, aligning with tertiary care's focus on restoring maximal health, critical in nursing to break readmission patterns and support long-term stability.
Which of the following is not true about the human needs?
- A. Certain needs are common to all people
- B. Needs should be followed exactly in accordance with their hierarchy
- C. Needs are stimulated by internal factors
- D. Needs are stimulated by external factors
Correct Answer: B
Rationale: Maslow's hierarchy (1940s) outlines needs physiological to self-actualization but they aren't rigidly sequential e.g., skipping food for a concert. Common needs (air, water), internal stimuli (hunger), and external triggers (stress) hold true. Nursing recognizes this flexibility, prioritizing patient-specific needs over strict order, enhancing individualized care planning.