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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Which of the following statement best describe crisis?
- A. A chronic condition
- B. A sudden event disrupting homeostasis
- C. A minor inconvenience
- D. A permanent state
Correct Answer: B
Rationale: Crisis is a sudden event disrupting homeostasis (B), per Caplan overwhelming balance (e.g., loss). Chronic (A) is ongoing, minor (C) understates, permanent (D) misframes crisis resolves. B best defines crisis's acute nature, making it correct.
One tablet of chlorine is efficient to chlorinate how many litres of water?
- A. 10 Litres
- B. 20 Litres
- C. 30 Litres
- D. 40 Litres
Correct Answer: B
Rationale: Chlorine tablets disinfect water by releasing hypochlorous acid to kill pathogens. Standard tablets (e.g., 1 mg chlorine) are designed to treat specific volumes based on concentration needs (typically 0.5-2 mg/L). Choice A (10 L) underestimates common tablet capacity, while C (30 L) and D (40 L) exceed typical single-tablet efficacy without specifying tablet strength. B (20 L) aligns with widely used chlorine tablets (e.g., NaDCC) for household water purification, achieving safe levels per WHO guidelines. Nurses educating communities on water safety must clarify dosage, ensuring effective pathogen control without overdose, making 20 L the correct, practical answer.
Which of the following statement is TRUE about evaluation in nursing process?
- A. First step of the process
- B. Determines if goals are met
- C. Only done once
- D. All of the above
Correct Answer: B
Rationale: Evaluation determines if goals are met (B), per process e.g., pain reduced? Not first (A, assessment), not once (C, ongoing), not all (D) outcome-focused. B truly defines evaluation's role, making it correct.
You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
- A. Stop working on these goals, as evaluation is the last step.
- B. Assess client's motivation for complying with the care plan.
- C. Reassess problem and then review care plan and revise as needed.
- D. Determine if the client has a knowledge deficit causing nonattainment.
Correct Answer: C
Rationale: When goals aren't met during evaluation, reassessing the problem and revising the care plan is the best action. This step identifies why outcomes like reduced swelling failed, perhaps due to an outdated intervention, and adjusts accordingly. Stopping assumes evaluation ends the process, ignoring its cyclical nature. Assessing motivation or knowledge deficits might inform revisions but isn't comprehensive without reassessment. This approach ensures care evolves with the client's condition, maintaining relevance and efficacy in the nursing process.
A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?
- A. Prepare for reintubation.
- B. Call the health care provider.
- C. Call the rapid response team.
- D. Check the client for spontaneous breathing.
Correct Answer: D
Rationale: If a tracheostomy tube is dislodged, checking for spontaneous breathing (D) is the priority to assess airway patency and oxygenation need. Preparing for reintubation (A) or calling teams (B, C) follows. D is correct. Rationale: Assessing breathing determines if immediate reinsertion or oxygenation is urgent, guiding next steps per respiratory emergency standards, ensuring patient stability first.