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Cards In This Set
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A patient had craniotomy 24 hours ago. Upon entering the patient’s room, the nurse called out her name, but the patient did not respond. What should the nurse do next?
a. Call out for help.
b. Check the patient’s pupils.
c. Gently shake the patient’s shoulders.
d. Check the patient’s vital signs.
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Answer: C
Rationale: After verbal stimulation and the client did not respond, tactile stimulation should be done, e.g. shaking the patient’s shoulders.
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The patient is diagnosed to have pulmonary tuberculosis. If he is transported out of the unit, what is the nurse’s appropriate intervention?
a. The patient should wear surgical mask.
b. The patient should wear gown and gloves.
b. The patient should wear eye protective device and gown.
d. The patient should wear eye protective device.
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Answer: A
Rationale: Pulmonary tuberculosis requires airborne precaution. The client should wear surgical mask when transported to another unit. The health care workers should wear particulate mask.
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Which of the following observations is normal in a 6-month old infant?
a. The child is able to turn on his abdomen but cannot return on his back.
b. The child falls back when left sitting alone.
c. The child crawls and creeps.
d. The child walks sideways as he holds on a furniture.
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Answer: B
Rationale: The 6-month old infant is able to sit for sometime. But if he is unsupported, he tends to fall back. The 9-month old infant can crawl and creep. The 10-12 month old infant walks sideways while holding on a furniture (cruising).
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Which of the following is contraindicated in a patient with Buck’s traction?
a. Foot clearance of 4 to 5 inches from the foot board.
b. Weights are hanging freely 6 inches from the floor.
c. Pillow is placed under the knees.
d. Turning the patient to the unaffected side.
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Answer: C
Rationale: Placing a pillow under the knees may cause venous stasis. This may result to thrombophlebitis. Choices A,B and D are correct interventions for the client with Buck’s traction.
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A man who had undergone bilateral above- the-knee amputation will be discharged home. Which of the following statements when made by the patient indicates the need for further teaching?
a. “When I’m in bed, I will elevate my stump on a pillow.”
b. “I will wear cotton stump socks.”
c. “I will wash the stump with warm water and mild soap.”
d. “When I sit, I will see to it that the stump is extended.”
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Answer: A
Rationale: The stump should be dependent on the mattress to prevent contractures. The stump should be elevated only during the first 24 hours postop, to prevent edema. Choices B, C, D are correct understanding on stump care.
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