Nursing Elites

1. What is a negative effect of immobility on the cardiovascular system?

• A. Increased high density lipoprotein
• B. Increased circulation
• C. Increased pumping action of the heart
• D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system as it can lead to blood clots.

2. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?

• A. Tell the client’s family that they will be expected to stay overnight
• B. Apply restraints to the client
• C. Shout to the client
• D. Orient the client to the location of objects in the room

Correct answer: D

Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.

3. The client had surgery one day ago. What assessment is most likely related to pain?

• A. Blood pressure of 175/90 mm Hg
• B. Respirations of 10 breaths per minute
• C. Heart rate 60 beats/minute
• D. Oxygen saturation of 97%

Correct answer: A

Rationale:

4. What is accurate health promotion teaching to prevent ear infection or trauma? (Select all that apply)

• A. Blow nose gently without blocking nostrils
• B. Wear hearing protection when exposed to loud noise
• C. Avoid using cotton-tipped applicators to clean the external ear
• D. All of the above

Correct answer: D

Rationale: The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.

5. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

• A. Once bacterial infection has caused damage, the tissue does not regenerate.
• B. Once retinal detachment occurs, it does not return to its normal state.
• C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
• D. Glaucoma always leads to permanent blindness.

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.

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