Title Nursing Therapeutics.pdf ✅

NURSES LICENSURE EXAMINATION (NLE) Controlled Copy 2023 Rev. 00 27. When assessing someone for chest percussion or chest vibration and postural drainage, you would focus on the following, EXCEPT: A. Respiratory rate, breath sounds and location of congestion B. Teaching the relatives to perform the procedure C. Amount of food and fluid taken during the last meal before treatment D. Physician's orders regarding restriction in positioning 28. The difference between chest percussion and vibration is: A. Percussion use only one hand while vibration uses both B. Percussion slaps chest to loosen secretions while vibration shakes secretion during inhalation C. They are the same, except that the hand positioning is different. D. Percussion delivers cushioned blows with cupped hands while vibration gently shakes secretion loose on exhalation cycle 29. You then prepare for postural drainage. What special considerations should you do? A. Respiratory rate of 16-20 breaths per minute B. Tolerance in sitting and lying position C. Patient has no sign of infection D. Time of last food and fluid intake 30. When performing CPT, you know that how many seconds should you suction a patient to not be at risk for any signs of hypoxia? A. 20-30 seconds B. 30-40 seconds C. 10-20 seconds D. Less than 10 seconds SITUATION – Mr. Balano, 80 years old, with an AV Fistula in his right arm, brought to the Emergency room for hypertension, flushed face, severe headache, and nausea. 31. You are to measure the client's initial blood pressure and all are correct, EXCEPT: A. Listen to and identify Korotkoff sounds B. Observe procedures for infection control C. Take blood pressure reading on both arms for comparison D. Pump the cuff around 30 mmHg above the point where the pulse is obliterated 32. The purpose of pulse oximeter attached to Mr. Balano's finger is: A. Determine the need for blood transfusion B. Check level of tissue perfusion C. Detect oxygen saturation of arterial blood before hypoxemia develops D. Measure efficacy of antihypertensive medications 33. The nurse find that the cuff is too narrow and this will cause the blood pressure reading to be: A. Inconsistent B. Low systolic, and high diastolic C. Higher sensitivity D. Higher specificity 34. When taking the blood pressure, Mr. Balano told you that he drank coffee just recently. How long should you wait so that the coffee will not affect the result? A. 15 minutes C. 1 hour B. 30 minutes D. 2 hours SITUATION – Mrs. Malala, 49 years old, queries you about her doubts that she is experiencing menopausal stage. 35. What instruction regarding urinary elimination will you INCLUDE? A. If burning sensation is happening while urinating, drink pineapple juice B. Hold urine as long as you can to strengthen sphincter muscles C. Empty the bladder each voiding D. After urination, wipe from anal area up to the pubis 36. You understand that one of these factors contributes to constipation: A. Prolonged use of laxatives B. Excessive exercise C. High fiber diet D. No regular time for defecation 37. She then tells the nurse that she is always constipated. What normal physiologic response of aging predisposes her to constipation? A. Weakness of sphincter muscles B. Inhibition of parasympathetic reflex C. Decreased ability to absorb fluids in lower intestines D. Loss of tone of smooth muscle in the colon 38. You will then do nasopharyngeal suctioning on Mr. Abad, Mrs. Malala's husband. Your guide for the length of insertion is: A. From tip of nose to the base of the neck B. From the distance of tip of the nose to the middle of the neck C. Eight to ten inches D. From the distance of tip of the nose to the tip of the ear lobe 39. You noticed that sunlight is shining on the pulse oximeter. Your action will be? A. Set and turn on the alarm for pulse oximeter B. Do nothing C. Change the location every 4 hours D. Cover the fingertip sensor with a towel or bedsheet SITUATION – Rwanda is a 19-year-old nursing student who always has questions about certain situations. 40. She asks how to correctly read the cuff when taking the blood pressure. Your answer would be? A. Deflate quickly after inflating up to 180 mmHg B. Inflate to 30 mmHg above the estimated systolic BP C. Deflate fully then start immediately the second reading for the same client D. Large enough to wrap around upper arm of adult client 1 cm above brachial artery