Nokea
You are preparing to assist a conscious patient with oral care. The patient has had a stroke, causing partial paralysis of his throat. Once the toothpaste, toothbrush, water, and emesis basin are set up on the overbed table, what will you do?
- A. Instruct the patient to brush her teeth and spit into the emesis basin, then leave the room.
- B. Ask a family member to assist the patient if she needs help while you are out of the room.
- C. Brush the patient's teeth for her, then instruct her to rinse her mouth with water and mouthwash while you prepare for the partial bath.
- D. Stay with the patient in case she chokes while performing oral care, and assist her as needed.
Correct Answer: D
Rationale: Due to partial throat paralysis from the stroke, the patient is at risk of choking or aspiration during oral care. Staying with the patient ensures safety and allows assistance as needed, preventing complications.
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Your patient is slightly confused. He has activity orders to be up in the chair three times per day. He is unstable on his feet when he walks or stands for more than a few minutes. What type of bath will you plan to give this patient?
- A. Bed bath
- B. Assisted or help bath
- C. Tub bath
- D. Shower
Correct Answer: B
Rationale: Given the patient's confusion and instability when standing for extended periods, an assisted or help bath is appropriate. This allows the nurse to provide support while the patient participates in bathing, accommodating their activity orders while ensuring safety. A bed bath is too restrictive, and a tub bath or shower poses a fall risk.
It is important to stay with a patient during the first bath or shower after surgery because the patient may
- A. Be unsteady while standing and sitting.
- B. Have an increase in pain when moving about.
- C. Cause the incision to open up when getting in the water.
- D. Experience vasodilation and become dizzy or faint.
Correct Answer: A,D
Rationale: Post-surgical patients may be weak or unsteady due to anesthesia effects or reduced mobility, increasing the risk of falls. Vasodilation from warm water can also cause dizziness or fainting, especially in a weakened state. While pain may increase with movement, it is not the primary concern for supervision, and incisions are unlikely to open from bathing alone.
You are caring for a patient with a nasogastric tube who is unable to take food or fluids by mouth. How often will you perform oral care for this patient?
- A. Unnecessary because the patient is not eating or drinking anything
- B. Every 2 hours
- C. Every 4 hours
- D. Every 8 hours
Correct Answer: B
Rationale: Patients with nasogastric tubes are at risk for dry mouth and oral infections due to lack of oral intake and tube irritation. Oral care every 2 hours helps maintain oral hygiene, prevent infections, and ensure patient comfort.
Your patient has multiple body piercings with jewelry in place. He has been in a motor vehicle accident and is scheduled for an MRI of his left arm and left leg. Which question will you ask this patient?
- A. Do I have your permission to remove the jewelry from your piercings before your MRI?
- B. Are the metals in your jewelry nonmagnetic stainless steel or titanium?
- C. You understand that you will need to remove all of the jewelry from your piercings before you go for an MRI, don't you?
- D. How long has the jewelry in your piercings been in place?
Correct Answer: B
Rationale: MRI machines use strong magnetic fields, and nonmagnetic metals like certain stainless steels or titanium are safe. Asking about the metal type ensures safety during the MRI, as magnetic metals can cause injury or imaging artifacts.
Label the following bed positions:
- A. Fowler's position
- B. Trendelenburg position
- C. Supine position
- D. Prone position
- E. Lateral position
- F. Sims' position
- G. Reverse Trendelenburg position
Correct Answer: A,B,C
Rationale: Common bed positions include Fowler's (head elevated), Trendelenburg (head lower than feet), and Supine (lying flat on back). These are standard positions used in patient care for comfort, breathing, or procedural needs.