1. Answer: B
Rationale: A client with anemia (decrease in red blood cells) has problem in transporting oxygen from the lungs to the tissue since hemoglobin, which is responsible in distributing oxygen to the different parts of the body, is located inside an RBC. With decrease number of RBC, a decrease in the number of oxygen-carrying hemoglobins also occurs.
2. Answer: C
Rationale: Hypoxemia refers to reduced oxygen in the blood. Cyanosis (option A) is the bluish discoloration of the skin, nailbeds and mucous membranes due to reduced hemoglobin-oxygen saturation. Hypoxia (option B) is a condition of insufficient oxygen anywhere in the body, from the inspired gas to the tissues. Anemia (option D) is a decrease in red blood cells.
3. Answer: C
Rationale: In performing nasopharyngeal suctioning, the length of insertion of the tubing for an adult would be the distance from the tip of the nose to the tip of the ear lobe.
4. Answer: C
Rationale: While doing nasopharyngeal suctioning, suction should only be applied while removing the catheter, not while inserting it, in order to prevent trauma to the trachea.
5. Answer: B
Rationale: Orthopnea is the inability to breathe except in an upright or standing position. Apnea (option A) is the cessation of breathing. Dyspnea (option C) is the difficulty or uncomfortable breathing. Tachypnea (option D) is an abnormally rapid respiratory rate.
6. Answer: B
Rationale: A 25- to 27-gauge needle measuring a half-inch in length is commonly used when administering an intradermal injection.
7. Answer: D
Rationale: The condition of the muscle tissue is an important factor that can influence the nurse's decision in administering intramuscular medications. Muscles can take a larger volume of fluid without discomfort than subcutaneous tissues can, although the amount varies among individuals, chiefly based on the muscle size and condition and the site used.
8. Answer: A
Rationale: Among the many kinds of drugs administered subcutaneously (just beneath the skin) are vaccines, insulin and heparin. Only small doses (0.5 to 1 ml) of medication are usually injected via the subcutaneous route.
9. Answer: A
Rationale: Intradermal injections are commonly used for diagnostic purposes such as skin testing. When giving an intradermal injection, the nurse instills the medication shallowly at a 10- to 15-degree angle of entry. 45-degree angle (option B) is used for subcutaneous injections. Option D is incorrect because 90-degree angle is used for intramuscular injections. Option C is inappropriate.
10. Answer: A
Rationale: The ventrogluteal site uses the gluteus medius and gluteus minimus muscles in the hip for injection. This site is safe for use in children. The vastus lateralis site uses the vastus lateralis muscle, one of the muscles in the quadriceps group of the outer thigh. It is a particularly desirable site for administering injections to infants and small children and clients who are thin or debilitated with poorly developed gluteal muscles. Dorsogluteal site is avoided in clients younger than 3 years because their muscle is not sufficiently developed. Deltoid site is only used for adults.
11. Answer: D
Rationale: Nurses commonly use terms to describe types of hygienic care. Hour of sleep (HS) or Afternoon (PM) care is provided to clients before they retire for the night. It usually involves providing for elimination needs, washing face and hands, giving oral care and giving a back massage. Providing back rub or massage to bedridden clients prevent the formation of pressure ulcers.
12. Answer: A
Rationale: To prevent aspiration of fluids into the lungs, the client is positioned on a side-lying position with head of bed lowered. In this position, the saliva automatically runs out by gravity rather than being aspirated into the lungs
13. Answer: D Rationale: Mouth care for unconscious or debilitated people is important because their mouths tends to become dry and consequently predisposed to tooth decay, mouth sores and infections. Normal saline is used if clients cannot tolerate the use of a toothbrush. Option A is incorrect because lemon glycerin swabs are not recommended as they irritate and dry the oral mucosa and can decalcify teeth. In option B, although hydrogen peroxide is approved as a mouth rinse, which provide a cleaning action as well as an antimicrobial effect, it is still diluted with a saline solution in order to decrease the burning sensation experienced by the client. Option C is incorrect because mineral oil is contraindicated because aspiration of it can initiate an infection.
14. Answer: B Rationale: The advantages of oral care for a client includes: (option A) decreases bacteria in the mouth and teeth; (option C) improves client’s appearance and self-confidence; and (option D) improves appetite and taste of food.
15. Answer: D
Rationale: The risk of fluid aspiration to the lungs can be avoided by suctioning as needed while cleaning the buccal cavity because fluid remaining in the mouth may be aspirated by the client.
16. Answer: A
Rationale: Low sodium diet is prescribed to clients with chronic renal problems. Common food sources rich in sodium are the following: table salt, soy sauce, canned foods (option B), processed foods and cheese (option C and D), milk, butter, ketchup, tomato, mustard, bacon and snack food.
17. Answer: D
Rationale: Common food sources high in cholesterol includes: animal products (option C), egg yolks (option A and B), whole milk,cooking oil, liver and organ meats. Fish (any fresh or frozen), canned crabs, lobster,salmon, tuna, clams, oysters, scallop, shrimp and sardines are considered low in cholesterol.
18. Answer: C Rationale: Clients on clear liquid diet are allowed to ingest only liquids that keep the GI tract empty (no residue). These foods are “see-through foods,” which includes water, tea, clear broth, jello, strained and clear juices, ginger ale, hard candy, clear carbonated beverages and frozen ice pops. Clear liquid diets also provides fluids and electrolytes to prevent dehydration. Options A and D, although considered clear liquid diets, option C provides more electrolytes need by a client with diarrhea. In option B, some orange juices are strained with its pulp while others are not.
19. Answer: A
Rationale: Home remedy to continue hydration therapy includes: rice based solution or “am,” tea, broth and breast milk.
20. Answer: B
Rationale: Clients with ulcerative colitis are instructed to consume a low residue and high protein diet and to avoid foods as whole wheat grains, nuts, raw fruits and vegetables. Gas-forming foods, milk products, caffeinated beverages, alcohol and pepper are also avoided. Bland diets are recommended because it excludes foods that may be chemically or mechanically stimulating or irritating to the GI tract.
21. Answer: D
Rationale: In transferring a client with a leg injury into a a wheelchair, instruct the client to move forward and sit on the edge of the bed. This is to bring the client's center of gravity closer to the nurse's. Then place the wheelchair on the client’s stronger side. In this way, the client can use the stronger leg muscles to stand and power the movement.
22. Answer: C
Rationale: Clients on dorsal recumbent position are placed on a back-lying position with knees flexed and hips externally rotated, small pillow is placed under the head, and the soles of the feet on the surface. Hyperextension of the knees should be prevented since it is done in a supine position
23. Answer: A
Rationale: In a high fowler’s position, the client's head and trunk are raised 90 degrees. Posterior flexion of the lumbar curvature is avoided since it is done in an orthopneic position
24. Answer: B
Rationale: In assisting a client to move up the bed, the nurse should first adjust the bed to flat position, then lock the wheels of the bed to prevent it from moving during moving, then raise the bed rails opposite the nurse to prevent unnecessary fall, then move the patient to the edge of the bed near the nurse before moving the client up to bring the client's center of gravity nearer to the nurse.
25. Answer: A
Rationale: Sandbags are used most effectively by the nurse to prevent external rotation of the injured leg.
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