Nokea
Which points should a nurse includes in the discharge teaching plan for a client after cardiac surgery?
- A. Avoid showers and take tub bath until all incisions are healed
- B. Notify the physician if a painless lump is felt at the top of the chest incision
- C. Continue to wear support hose or elastic stockings during the night and remove them during the day
- D. Sexual relations typically can be resumed in 2-4 weeks depending on tolerance for activity
Correct Answer: B
Rationale: The correct answer is B because it addresses the importance of notifying the physician about a painless lump at the top of the chest incision, which could indicate a serious complication like a seroma or hematoma. This is crucial for early detection and intervention.
A is incorrect because showers are generally allowed after cardiac surgery as long as the incisions are kept clean and dry.
C is incorrect because support hose or elastic stockings are typically recommended to be worn during the day and removed at night to prevent swelling and promote circulation.
D is incorrect because resuming sexual relations after cardiac surgery should be based on individual recovery and should be discussed with the healthcare provider, rather than a standard timeframe.
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What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
- A. Fr. 5
- B. Fr. 12
- C. Fr. 10
- D. Fr. 18
Correct Answer: A
Rationale: The correct size of suction catheter for James would be Fr. 5. The selection of suction catheter size is based on the patient's height and weight, as well as the secretions to be cleared. A Fr. 5 catheter is appropriate for an average adult like James, as it balances between being too small or too large. Fr. 12 and Fr. 18 are too large for his size and could cause trauma, while Fr. 10 is slightly larger than needed, increasing the risk of mucosal damage. Therefore, Fr. 5 is the most suitable choice for James.
Which of the ff. nursing interventions will help prevent complications in the patient with Bell’s Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Correct Answer: D - Lubricating eye drops
Rationale: Lubricating eye drops help prevent complications such as corneal abrasions in patients with Bell's Palsy by keeping the eye moist and preventing dryness. Bell's Palsy can cause difficulty in closing the eye properly, leading to dryness and potential damage to the cornea. Using lubricating eye drops helps maintain eye health.
Summary of Incorrect Choices:
A: Megavitamin therapy - Not directly related to preventing complications in Bell's Palsy.
B: Application of ice to the affected area - Ice may not address eye dryness or prevent corneal abrasions.
C: Elastic bandages - Not relevant to preventing complications associated with Bell's Palsy.
Following the American Cancer Society guidelines, the nurse should recommend that the women:
- A. Perform breast self-examination annually
- B. Have a physician conduct a clinical
- C. Have a mammogram annually examination every 2 years
- D. Have a normal receptor assay annually
Correct Answer: C
Rationale: The correct answer is C because the American Cancer Society recommends women to have a mammogram annually starting at age 45, then have the option to transition to biennial screening at age 55. This recommendation is based on evidence that regular mammograms can help detect breast cancer early, increasing chances of successful treatment. Choice A is incorrect because self-examinations are no longer recommended as a routine screening method. Choice B is incorrect as clinical breast exams are not as effective as mammograms for detecting breast cancer. Choice D is incorrect as normal receptor assays are not part of routine breast cancer screening guidelines.
Nurse Carlos teaches a community adult class about the common symptoms of tuberculosis. Which of the following should Nurse Carlos include?
- A. weight loss
- B. dyspnea on exertion
- C. increased appetite
- D. mental status changes
Correct Answer: A
Rationale: The correct answer is A: weight loss. Weight loss is a common symptom of tuberculosis due to the impact of the infection on the body's metabolism and appetite. This symptom is important to recognize as it can be an early indicator of the disease. Dyspnea on exertion (B) is not a common symptom of tuberculosis, as it typically affects the lungs rather than causing difficulty breathing. Increased appetite (C) is not a typical symptom, as TB usually leads to decreased appetite and weight loss. Mental status changes (D) are not directly associated with tuberculosis and are more commonly seen in other conditions affecting the brain. Therefore, weight loss is the most relevant symptom to include in the teaching material for identifying possible cases of tuberculosis.
Which of the following is the humoral immune response?
- A. B cells phagocytise the foreign antigen
- B. T cells are stimulated by B cells and turn into plasma cells, which produce antibodies or memory cells.
- C. B cells are stimulated by T helper cells or macrophages and turn into plasma cells, which produce antibodies or memory cells.
- D. T cells produce antibodies.
Correct Answer: C
Rationale: The correct answer is C because in the humoral immune response, B cells are stimulated by T helper cells or macrophages to differentiate into plasma cells that produce antibodies or memory cells. This process involves the production of specific antibodies that target the foreign antigen.
Choice A is incorrect because B cells do not phagocytize antigens; instead, they produce antibodies.
Choice B is incorrect because T cells do not turn into plasma cells. It is the B cells that differentiate into plasma cells in the humoral immune response.
Choice D is incorrect because T cells do not produce antibodies. T cells are involved in cell-mediated immunity, not the humoral immune response.