Nokea
A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. Which factor indicates further information is needed by the nurse?
- A. The client's dietary habits include foods high in bulk
- B. The client's fluid intake is between 2500-3000 ml per day
- C. The client engages in moderate exercise each day
- D. The client's bowel habits were not discussed
Correct Answer: D
Rationale: Bowel habits are essential to tailor a training regimen; their absence indicates a gap.
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When examining the client's abdomen, the nurse will most facilitate the examination by positioning the client in which of the following ways?
- A. supine with small pillows beneath knees and head
- B. semi-Fowler's position with knees extended
- C. sitting in the chair with legs elevated
- D. supine with arms extended and hands behind head
Correct Answer: A
Rationale: Supine with pillows under knees and head relaxes abdominal muscles, aiding examination, unlike semi-Fowler's, sitting, or arms-up positions. Nurses use this for effective assessment.
Provides a concise method of organizing and recording data about the client. It is a series of flip cards kept in portable file used in change of shift reports.
- A. Kardex
- B. Progress Notes
- C. SOAPIE
- D. Change of shift report
Correct Answer: A
Rationale: Kardex (A) is a concise, card-based system for shift reports, per nursing practice. Progress notes (B) detail chronologically, SOAPIE (C) structures per problem, shift reports (D) are verbal. A fits the portable file description, making it correct.
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
- A. Place the probe on the child's abdomen
- B. Recalibrate the oximeter at the beginning of each shift
- C. Apply the probe and wait 15 minutes before obtaining a reading
- D. Place the probe on the child's finger
Correct Answer: D
Rationale: Placing the pulse oximeter probe on the finger ensures an accurate oxygen saturation reading in an 8-year-old, as peripheral sites like fingers provide reliable arterial pulsation data. The abdomen isn't suitable, recalibration isn't routine, and waiting 15 minutes delays care unnecessarily. Nurses use this technique for quick, precise monitoring, critical in respiratory infections to guide oxygen therapy.
Which of the following is considered as an example of intentional tort?
- A. Malpractice
- B. Negligence
- C. Breach of duty
- D. False imprisonment
Correct Answer: D
Rationale: False imprisonment, an intentional tort, involves deliberately restricting someone's freedom, like restraining a competent patient against their will. Malpractice and negligence are unintentional torts, stemming from carelessness or failure to meet standards, not intent. Breach of duty is a negligence component, not a standalone tort. In nursing, intentional torts require purposeful action, and false imprisonment risks legal liability, emphasizing patient rights and consent in care delivery.
A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
- A. Host
- B. Agent
- C. Environment
- D. Disease
Correct Answer: B
Rationale: In the Agent-Host-Environment Model, Staphylococcus is the agent the causative factor triggering illness, here infecting a decubitus ulcer. The client is the host, whose skin integrity and immunity determine susceptibility. The environment bedridden conditions or hygiene sets the stage for infection. The disease is the resulting pathology, like the ulcer's worsening. This model dissects causation: Staphylococcus (bacteria) invades the host (client) in a conducive environment (immobility), driving nursing interventions cleaning wounds, repositioning to disrupt the triad. Understanding the agent's role guides targeted care, like antibiotics, breaking the infection cycle. It's a practical lens for nurses, pinpointing external triggers to prevent or manage illness effectively, especially in chronic wound scenarios.