RN

1. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

• A. Amount of food and fluid taken during the last meal before treatment
• B. Respiratory rate, breath sounds, and location of congestion
• C. Teaching the client's relatives to perform the procedure
• D. Doctor's order regarding position restrictions and client's tolerance for lying flat

Correct Answer: B

Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.

2. A patient is being discharged with a vitamin K deficiency. What food should the nurse recommend to the patient to include in their diet?

• A. Oranges
• B. Spinach
• C. Fish
• D. Nuts

Correct Answer: B

Rationale: Spinach is an excellent source of vitamin K, which plays a vital role in blood clotting and bone health. Oranges, fish, and nuts do not contain significant amounts of vitamin K, making them less suitable choices to address a vitamin K deficiency. Therefore, the correct recommendation for a patient with a vitamin K deficiency would be to include spinach in their diet to help replenish this essential vitamin.

3. When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

• A. 10-15 seconds
• B. 30-35 seconds
• C. 20-25 seconds
• D. 0-5 seconds

Correct Answer: D

Rationale: During endotracheal suctioning, the nurse should apply suctioning while withdrawing and gently rotating the catheter 360 degrees for a short period of 0-5 seconds. This brief duration helps minimize the risk of hypoxia and trauma to the airway. Choices A, B, and C suggest longer time periods for suctioning, which can increase the risk of complications such as hypoxia, mucosal damage, and the removal of excess amounts of airway secretions.

4. Which statement indicates understanding of a low-fiber diet?

• A. I can cut up carrots and celery sticks for my lunch.
• B. I will eat a bran muffin for my mid-morning snack.
• C. I will have oatmeal with skim milk for my breakfast.
• D. I should choose canned peaches for my fruit serving.

Correct Answer: D

Rationale: The correct answer is D because canned peaches are low in fiber compared to the other options provided. Option A contains high-fiber vegetables (carrots and celery), option B includes a bran muffin which is fiber-rich, and option C involves oatmeal which is also a good source of fiber. Therefore, choosing canned peaches aligns with a low-fiber diet.

5. All of the following are contraindications when giving Immunization except:

• A. BCG Vaccine can be given to a child with AIDS
• B. BCG Vaccine can be given to a child with Hepatitis B
• C. DPT can be given to a child that had convulsion 3 days after being given the first DPT dose
• D. DPT can be given to a child with active convulsion or other neurological disease

Correct Answer: B

Rationale: The correct answer is B. BCG vaccine can be given to a child with Hepatitis B, as there is no contraindication for this. Choice A, C, and D all present contraindications for administering immunizations. Choice A is incorrect because giving BCG vaccines to a child with AIDS is a contraindication. Choice C is incorrect as convulsions after the first DPT dose indicate a contraindication to subsequent doses. Choice D is incorrect because active convulsions or other neurological diseases are contraindications to receiving the DPT vaccine.