Nokea
Which part of the brain controls breathing?
- A. Medulla
- B. Cerebrum
- C. Cerebellum
- D. Thalamus
Correct Answer: A
Rationale: The correct answer is A: Medulla. The medulla is located in the brainstem and plays a crucial role in controlling involuntary functions like breathing. It contains the respiratory center, which regulates the rate and depth of breathing. The medulla sends signals to the diaphragm and intercostal muscles to control breathing. The cerebrum (B) is responsible for higher brain functions, not breathing control. The cerebellum (C) coordinates movement and balance, not breathing. The thalamus (D) relays sensory information to the cerebral cortex, not involved in breathing regulation.
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A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.)
- A. Observations of wound healing
- B. Daily blood pressure measurements
- C. Findings of respiratory rate and depth
- D. Completion of nursing interventions NursingStoreRN
Correct Answer: A
Rationale: The correct answer is A: Observations of wound healing. This is the correct evaluative measure because it directly assesses the patient's response to nursing care, indicating the effectiveness of interventions. Wound healing is a tangible and visible indicator of the patient's overall health status and the success of nursing interventions.
The other choices are incorrect:
B: Daily blood pressure measurements do not solely indicate a patient's response to nursing care. Blood pressure can be affected by various factors unrelated to nursing interventions.
C: Findings of respiratory rate and depth are important for assessing respiratory status but may not directly reflect the patient's response to nursing care.
D: Completion of nursing interventions is a process measure and does not provide direct insight into the patient's response to care.
The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
- A. Protocols are guidelines to follow that replace the nursing care plan. Protocols assist the clinician in making decisions and choosing interventions for specific
- B. health care problems or conditions. Protocols are policies designating each nurse’s duty according to standards of care and a
- C. code of ethics.
- D. Protocols are prescriptive order forms that help individualize the plan of care.
Correct Answer: A
Rationale: The correct answer is A because protocols are indeed guidelines that assist clinicians in decision-making and choosing interventions for specific health care problems. This definition accurately reflects the purpose and function of protocols in nursing practice.
Option B is incorrect as it describes protocols as policies related to nurses' duties and standards of care, which is more aligned with job descriptions and policies rather than protocols.
Option C is incorrect as it relates protocols to a code of ethics, which is a separate concept that guides ethical decision-making and behavior in nursing practice.
Option D is incorrect as it inaccurately describes protocols as prescriptive order forms, which are actually separate from protocols and are used for medication administration and treatment orders.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Asking the NAP to record the patient's vital signs before administering medications is the correct clinical decision. Vital signs are crucial indicators of a patient's health status and should be documented before any interventions. By having the NAP record the vital signs, the nurse ensures that the patient's condition is properly assessed and monitored. This action aligns with the standard of care and promotes patient safety.
Summary of Incorrect Choices:
A: Administering medications without knowing the patient's vital signs could be dangerous, especially if there are abnormalities that need attention.
B: Reviewing vital signs upon return delays necessary assessment and intervention, potentially compromising patient safety.
D: Omitting vital signs without assessment puts the patient at risk, as changes in vital signs can indicate underlying issues that need immediate attention.
Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
- A. Restrict fluid intake
- B. Ensure that the client avoids prolonged sitting
- C. Position lower extremities below level of heart
- D. Instruct the client to avoid leg exercises
Correct Answer: C
Rationale: The correct answer is C: Position lower extremities below level of heart. This intervention helps improve blood flow and perfusion to the lower extremities by utilizing gravity to assist in venous return. This is crucial for clients at risk for ineffective tissue perfusion post-cardiac surgery.
A: Restricting fluid intake may lead to dehydration, which can worsen tissue perfusion.
B: Ensuring the client avoids prolonged sitting is important for preventing blood clots, but it does not directly address tissue perfusion.
D: Instructing the client to avoid leg exercises may hinder circulation and exacerbate issues related to tissue perfusion.
An adult is on a clear liquid diet. Which food item can be offered/
- A. Milk
- B. Orange juice
- C. Jello
- D. Ice cream
Correct Answer: C
Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids and foods that are liquid at room temperature. Jello meets this criteria as it is a clear, easily digestible food. Milk (A) is not allowed on a clear liquid diet due to its opaque nature. Orange juice (B) contains pulp and is not considered clear. Ice cream (D) is a solid food and not permitted on a clear liquid diet. Therefore, Jello is the most suitable option for someone on a clear liquid diet.