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CASAL OA REVIEW: Questions With Detailed Solutions
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CASAL OA REVIEW: Questions With Detailed Solutions
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CASAL OA REVIEW: Questions With Detailed SolutionsHealth perception Right Ans - how the person describes and defines
personal health
First-Level Priority Problems Right Ans - emergent, life-threatening, and
immediate, such as establishing an airway or supporting breathing
Second-Level Priority Problems Right Ans - those that are next in urgency
requiring your prompt intervention to forestall further deterioration.
Third-Level Priority Problems Right Ans - Important to the patient's health
but can be addressed after more urgent health problems are addressed
Nurse Manager Right Ans - who is in-charge of improving coordination of
care and reducing the fragmentation of care
BMI ranges: (3) Right Ans - - Obese: 30 <
- Overweight: 25 - 30
- Normal: 18 - 24
What should the nurse do to demonstrate proper body mechanics when
assisting a client to a standing position from a sitting position? (Select all that
apply.)
Rock their own body weight as they pull the client up towards them.
Keep their own knees locked as they lift the client in a smooth motion.
Stand in front of the client, move their own feet apart and bend at the knees.
While standing behind the client, secure their own arms around the client's
chest and lift upward.
Assess the client and determine whether or not another care provider is
needed to assist. Right Ans - Rock their own body weight as they pull the
client up towards them.
Stand in front of the client, move their own feet apart and bend at the knees.
,Assess the client and determine whether or not another care provider is
needed to assist.
Rationale
Pulling is easier than lifting and the momentum by rocking the nurse's body
uses that body weight to enhance the force of arm muscles. Moving feet apart
widens the base of support and bending knees lowers the center of gravity.
These actions are elements of safe body mechanics. When possible, use teams
to lift clients ast is decreases the incidences of lower back injuries in
healthcare workers and is safer for the client.
Which assessment data would provide the most accurate determination of
proper placement of a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
D) Checking the remaining length of tubing to ensure that the correct length
was inserted. Right Ans - C) Examining a chest x-ray obtained after the
tubing was inserted
Both (A and B) are methods used to determine proper placement of the NG
tubing. However, the best indicator that the tubing is properly placed is (C).
(D) is not an indicator of proper placement
The nurse is assessing a client for risk of falls. Which client behavior would be
the most informative to the nurse?
The client transfers unassisted from the bed to a chair next to the bed.
The client changes positions in bed from a prone position to sitting upright at
45 degrees.
The client is able to rise from a chair without using arms for support and walk
10 feet and turn around.
,The client with gait belt attached ambulates up and down the hallway with the
physical therapist next to them. Right Ans - The client is able to rise from a
chair without using arms for support and walk 10 feet and turn around.
Rationale
A client's ability to get up from a sitting position without using their arms for
support and walk 10 feet and turn around would give the nurse an assessment
of the client's balance, coordination and gait as they walked.
When assisting an 82-year-old client to ambulate, it is important for the nurse
to realize that the center of gravity for an elderly person is the
A) Arms.
B) Upper torso.
C) Head.
D) Feet Right Ans - B) Upper torso
The center of gravity for adults is the hips. However, as the person grows
older, a stooped posture is common because of the changes from osteoporosis
and normal bone degeneration, and the knees, hips, and elbows flex. This
stooped posture results in the upper torso (B) becoming the center of gravity
for older persons. Although (A) is a part, or an extension of the upper torso,
this is not the best and most complete answer.
Reduce dietary sodium to less than ___ mg Right Ans - 2300 mg
What nursing interventions should be implemented for a client whose
absolute neutrophil count (ANC) is below 500?
Admit to a reverse isolation room.
Begin bleeding precaution protocol.
Caution against any cut flowers in client's room.
Screen and limit individuals wishing to visit.
Provide only fresh organic fruits and vegetables. Right Ans - Admit to a
reverse isolation room.
, Screen and limit individuals wishing to visit.
Caution against any cut flowers in client's room.
Rationale
The client has neutropenia and is at risk for infection. A reverse isolation,
positive pressure room is the best choice for these clients. Cut flowers and live
plants, along with fruits and vegetables have been shown to carry organisms
that could cause harm to the immuno-compromised client. Visitors of these
clients need to be limited and screen for possible signs of infection which
could be lethal to an immuno-compromised client.
Which action is most important for the nurse to implement when donning
sterile gloves?
A) Maintain thumb at a ninety degree angle.
B) Hold hands with fingers down while gloving.
C) Keep gloved hands above the elbows.
D) Put the glove on the dominant hand first. Right Ans - C) Keep gloved
hands above the elbows
Gloved hands held below waist level are considered unsterile (C). (A and B)
are not essential to maintaining asepsis. While it may be helpful to put the
glove on the dominant hand first, it is not necessary to ensure asepsis (D).
Do obese children generally become obese adults? Right Ans - Yes
An adult male client with a history of hypertension tells the nurse that he is
tired of taking antihypertensive medications and is going to try spiritual
meditation instead. What should be the nurse's first response?
A) It is important that you continue your medication while learning to
meditate.
B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily.
C) Obtain your healthcare provider's permission before starting meditation.
D) Complementary therapy and western medicine can be effective for you.
Right Ans - A) It is important that you continue your medication while
learning to meditate
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