Nokea
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
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When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire?
- A. Class A
- B. Class B
- C. Class C
- D. Class E
Correct Answer: C
Rationale: An electrical fire requires a Class C extinguisher, designed for energized electrical equipment like appliances or wiring. Class A suits ordinary combustibles (wood), Class B handles flammable liquids, and Class E isn't standard (often confused with electrical but not U.S.-classified). Using a Class C extinguisher, typically with non-conductive agents like carbon dioxide, ensures safety by avoiding shock while extinguishing. This choice protects both the nurse and client in a healthcare setting, aligning with fire safety protocols.
The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: All are critical to monitor bleeding risks and heparin efficacy.
Which activity is an example of health promotion by the nurse
- A. Administering immunizations
- B. Giving a bedbath
- C. Preventing complications after an accident
- D. Performing diagnostic procedures
Correct Answer: A
Rationale: Health promotion enhances well-being and prevents disease proactively administering immunizations (e.g., measles vaccine) exemplifies this, boosting immunity before illness strikes. Giving a bedbath is hygiene, not promotion supportive, not preventive. Preventing complications post-accident is tertiary prevention, managing existing issues, not promoting health preemptively. Diagnostic procedures (e.g., blood tests) detect, not promote assessment, not prevention. Immunizations align with health promotion's focus on empowering clients against disease, a core nursing role in public health, making this the standout example.
The nurse reported Mr. Gary's fall to improve safety. This is an example of?
- A. Incident reporting
- B. Documentation
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Reporting a fall is incident reporting (A) adverse event log, per definition. Documentation (B) records, promotion (C) well-being, transition (D) moves not report-specific. A fits the nurse's action for Mr. Gary's safety, making it correct.
The goal of nursing is to put the patient in the best condition for nature to act upon him'. This was stated by
- A. Henderson
- B. Jean Watson
- C. Marta Rogers
- D. Florence Nightingale
Correct Answer: D
Rationale: This quote reflects a historical view of nursing as facilitating natural healing, attributed to Florence Nightingale, the founder of modern nursing. In her 1859 work, *Notes on Nursing*, she emphasized optimizing the patient's environment cleanliness, air, and rest for recovery. Henderson defined nursing through 14 basic needs, Watson focused on caring theory, and Rogers developed a science of unitary beings none match this phrasing. Nightingale's philosophy shaped nursing's focus on holistic care, influencing practice for centuries by prioritizing patient conditions over direct intervention.