Nokea
You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:
- A. Take the blood pressure reading on both arms for comparison
- B. Listen to and identify the phases of Korotkoff sounds
- C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
- D. Observe procedures for infection control
Correct Answer: B
Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.
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What is the purpose of the cuff in a Tracheostomy tube?
- A. Separate the upper and lower airway
- B. Separate trachea from the esophagus
- C. Separate the larynx from the nasopharynx
- D. Secure the placement of the tube
Correct Answer: B
Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.
How many words does a typical 12-month-old infant use?
- A. About 12 words
- B. Twenty or more words
- C. About 50 words
- D. Two, plus 'mama' and 'papa'
Correct Answer: D
Rationale: A typical 12-month-old infant typically uses very few words, with 'mama' and 'papa' being common early words. At this age, most infants are still in the early stages of language development, and their vocabulary is limited. Choices A, B, and C suggest higher word counts which are not typical for infants at this age.
The nurse knows that after receiving the blood from the blood bank, it should be administered within:
- A. 1 hour
- B. 2 hours
- C. 4 hours
- D. 6 hours
Correct Answer: D
Rationale: Blood transfusions need to be administered promptly after receiving the blood from the blood bank to ensure patient safety and effectiveness. Waiting too long can lead to complications such as bacterial growth in the blood product, which can be harmful when infused. Administering the blood within 6 hours is crucial to prevent such risks. Choices A, B, and C are incorrect because waiting for 1, 2, or 4 hours respectively can increase the likelihood of complications associated with delayed transfusion.
A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:
- A. perfusion
- B. locomotion
- C. respiration
- D. mentation
Correct Answer: D
Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.
The recommended treatment modality in clients with obsessive-compulsive disorder is:
- A. Psychotherapy
- B. Behavior therapy
- C. Aversion therapy
- D. Psychoanalysis
Correct Answer: B
Rationale: The recommended treatment modality for clients with obsessive-compulsive disorder is Behavior Therapy, not Psychoanalysis. Behavior therapy, specifically exposure and response prevention, is considered the first-line treatment for OCD. This therapy focuses on changing the patterns of behavior that contribute to the disorder. Psychotherapy, although beneficial in some cases, is not as effective as behavior therapy for OCD. Aversion therapy involves associating a stimulus with a negative outcome to reduce the frequency of a specific behavior, which is not the primary approach for OCD.