Nokea
A nurse is caring for a 10 year-old boy who has just been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?
- A. Increased body weight
- B. Elevated heart rate
- C. Lower extremity edema
- D. Compulsive behavior
Correct Answer: D
Rationale: Compulsive behavior does not indicate CHF.
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Who is responsible for obtaining the signature from the client on the informed consent?
- A. the staff nurse
- B. the charge nurse
- C. the LPN
- D. the physician
Correct Answer: D
Rationale: It is the physician's responsibility to obtain the client's signature. The nurse is responsible for verifying that this occurred.
All of the following factors, when identified in the history of a family, are correlated with poverty except:
- A. high infant mortality rate.
- B. frequent use of Emergency Departments.
- C. consultation with folk healers.
- D. low incidence of dental problems.
Correct Answer: D
Rationale: Dental problems are prevalent because of the lack of preventive care and access to care. High infant mortality is one of the most significant problems correlated with poverty. Pregnant women who do not have access to care might come to the Emergency Department when in labor. Those in poverty are likely to use Emergency Departments because they may not be turned away. Those in poverty might also turn to folk healers or other persons in their community for care who might be easier to access and might not demand payment.
A nurse is giving shift report off to the oncoming LPN. Which of these is an inappropriate shift report?
- A. The nurse gives report to the oncoming LPN, checking a wound vac and dressing together.
- B. The nurse reports in SBAR format, noting that the client was noncompliant with their diet during the shift.
- C. The nurse reports in the hallway, SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
- D. The nurse reports at bedside with the oncoming LPN and discusses the client's concerns after the chart has been reviewed.
Correct Answer: C
Rationale: Report should be at the bedside, in SBAR format, and given in an objective way.
During an emergency procedure, is the surgical timeout a requirement?
- A. As long as the surgical timeout would not cause a delay leading to injury or death, the time-out should be performed by the surgical team.
- B. No, in an emergency procedure, the timeout does not need to be performed.
- C. No, the surgical timeout is optional depending on the surgeon's preferences.
- D. Yes, the surgical timeout should be performed in all cases.
Correct Answer: A
Rationale: The surgical timeout should be performed as long as the delay in performing the timeout would not have negative consequences.
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
- A. 6
- B. 8
- C. 12
- D. 16
Correct Answer: C
Rationale: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 - 6 = 12. An 18-month-old child should have approximately 12 teeth.