Nokea
Which patient is ready for discharge from Phase I PACU care to the clinical unit?
- A. Arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88%
- B. Difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91%
- C. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
- D. Arouses, blood pressure (BP) higher than preoperative and respiratory rate is 10, no excess bleeding, SaO2 is 90%
Correct Answer: C
Rationale: Stable vital signs, intact dressing, and adequate oxygenation indicate readiness for transfer.
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What accurately describes the health care system in which future nurses will be employed?
- A. With improvements in medicine there will be fewer patients with chronic illnesses
- B. Rapidly changing technology and expanding knowledge will simplify the health care environment
- C. The Quality and Safety Education for Nurses (QSEN) project measures the ability of nursing graduates to be prepared for the reality of practice
- D. The Joint Commission establishes National Patient Safety Goals and evidence-based solutions for nurses to promote meeting these goals by all caring for the patient
Correct Answer: C
Rationale: The QSEN project focuses on preparing nurses for real-world practice, and The Joint Commission sets safety goals. Chronic illnesses are increasing due to aging populations, and technology adds complexity rather than simplifying the environment.
Mr. and Mrs. Smith took part in a community health screening. What does a positive reaction to the standard intermediate strength PPD mean?
- A. Have active tuberculosis
- B. Are “carriers” of tuberculosis
- C. Have already transmitted tuberculosis to their children
- D. Have been exposed to active tuberculosis
Correct Answer: D
Rationale: A positive PPD test indicates past exposure to Mycobacterium tuberculosis but does not confirm active disease.
Mrs. Blakely's postoperative course is otherwise uneventful, and she is fitted with corrective glasses. For Mrs. Blakely to adjust to wearing her new eyeglasses, it would be most important to teach her that
- A. the color of objects seen with the operated eye is much brighter
- B. her new glasses will be much heavier
- C. she will have binocular vision
- D. she will have considerable distortion in vision
Correct Answer: A
Rationale: After cataract surgery, colors may appear brighter due to the removal of the cloudy lens, which previously muted perception of certain wavelengths.
Priority Decision: A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient’s husband and two grown children are arguing at the bedside about where the patient’s funeral should be held. What should the nurse do first?
- A. Ask the family members to leave the room if they are going to argue.
- B. Take the family members aside and explain that the patient may be able to hear them.
- C. Tell the family members that this decision is premature because the patient has not yet died.
- D. Remind the family that this should be the patient’s decision and to ask her if she regains consciousness.
Correct Answer: B
Rationale: The patient may still be able to hear even if unresponsive, so the nurse should gently remind the family of this to maintain respect for the patient's dignity and provide emotional support.
Which is an essential component of quality care for dying clients?
- A. Assist the client with personal hygiene.
- B. Inform all members of healthcare regarding the client’s prognosis.
- C. Provide sensitivity and compassion for the client and their family members.
- D. Promote the care of dying clients at home or in hospice settings.
Correct Answer: C
Rationale: Sensitivity and compassion address emotional and psychological needs, enhancing end-of-life care.