Nokea
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?
- A. Conductive
- B. Mixed
- C. Sensorineural
- D. Central
Correct Answer: C
Rationale: Sensorineural hearing loss occurs when there is damage to the inner ear (cochlea) or the auditory nerve. This type of hearing loss is most commonly associated with aging or prolonged exposure to loud noises. Sensorineural hearing loss is typically permanent and cannot be medically or surgically corrected; however, it can be effectively managed with hearing aids. A hearing aid can amplify sound and help individuals with sensorineural hearing loss improve their ability to hear and communicate effectively. Conductive and mixed hearing losses may benefit from other interventions such as surgical procedures, while central hearing loss is related to the processing of sound in the brain and is not effectively managed by hearing aids.
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The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The multilumen pulmonary artery catheter, when positioned in the small branches of the pulmonary artery, allows the nurse to measure various hemodynamic pressures. Central venous pressure (CVP), Pulmonary artery capillary pressure (PACP), and Pulmonary artery wedge pressure (PAWP) can be measured accurately at this point. However, "Pulmonary artery obstructive pressure" is not a valid or recognized hemodynamic pressure parameter. Instead, the correct term for this measurement that can be assessed using the catheter is the Pulmonary artery occlusion pressure (PAOP) or Pulmonary artery wedge pressure (PAWP), which reflects the left atrial pressure.
Which should the nurse recommend to prevent urinary tract infections in young girls?
- A. Wear cotton underpants.
- B. Limit bathing as much as possible.
- C. Increase fluids; decrease salt intake.
- D. Cleanse perineum with water after voiding.
Correct Answer: A
Rationale: Cotton underpants are recommended to prevent urinary tract infections in young girls because they allow for better air circulation, which helps keep the genital area dry and reduces the likelihood of bacterial growth. Synthetic materials can trap moisture and create a warm and moist environment that promotes bacterial infections. Therefore, wearing cotton underpants is a simple and effective way to promote good hygiene and prevent urinary tract infections in young girls.
A patient reports on admission being "very sick" after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding giving the antibiotic?
- A. Give the antibiotic
- B. Do not give the antibiotic
- C. Give half of the dose
- D. Discontinue the antibiotic
Correct Answer: B
Rationale: In this scenario, the patient reports being "very sick" after taking erythromycin in the past, indicating a history of adverse reaction to the medication. Given this information, it would be most prudent to withhold the erythromycin to prevent a potential adverse reaction or worsening of the patient's condition. It is important for the nurse to always consider the patient's previous experiences and adverse reactions when administering medications to ensure patient safety.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: It is crucial to give the patient with aphasia time to complete their sentence. Aphasia can impact a person's ability to find the right words, so allowing them the time to express themselves can be helpful. Rushing or providing excessive cues could lead to frustration and may not allow the patient the opportunity to find the appropriate words on their own. Being patient and giving the individual time to communicate can be empowering and supportive.
A client was brought to the emergency room with complains of difficulty of breathing. What can lead the nurse to suspect that the client is experiencing acute respiratory distress syndrome (ARDS)?
- A. paO2 of 95, pCO2 of 43, x-ray showing enlarged heart, bradycardia
- B. Thick green sputum production, paO2 of 74, pH of 7.41
- C. restlessness, suprasternal retractions, paO2 of 62
- D. wheezes, slow, deep respirations, pCO2 of 52, pH of 7.35
Correct Answer: C
Rationale: Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure characterized by rapidly progressive dyspnea, hypoxemia, and noncardiogenic pulmonary edema. The key signs of ARDS include severe respiratory distress, low partial pressure of oxygen (paO2), and bilateral infiltrates on chest x-ray. In the given scenario, the client presenting with restlessness and suprasternal retractions along with a paO2 level of 62 indicates severe respiratory distress and hypoxemia, which are consistent with ARDS. Therefore, option C is the most indicative of ARDS among the choices provided.