Nokea
A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?
- A. Apply a heat lamp to the area for 20 minutes each day.
- B. Change the dressing on the heel every 12 hours.
- C. Apply a transparent dressing over the heel.
- D. Use a water pressure mattress.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which of the following statement is TRUE about responsibility?
- A. The nurse can delegate all her tasks
- B. Means the nurse is liable for her actions
- C. The nurse should not accept tasks she's not competent
- D. All of the above
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
- A. Cherry-red urine that gradually becomes clearer
- B. Orange-tinged urine containing particles of calculi
- C. Dark red urine that becomes cloudy in appearance
- D. Dark, smoky-colored urine with high specific gravity
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery?
- A. Obturator
- B. Oral airway
- C. Epinephrine
- D. Tracheostomy tube with the next larger size
Correct Answer: A
Rationale: Post-tracheostomy, the obturator (A) is essential at the bedside to reinsert the tube if dislodged, ensuring airway patency. An oral airway (B) is irrelevant for tracheostomy patients. Epinephrine (C) treats allergic reactions, not routine needs. A larger tracheostomy tube (D) isn't standard emergency equipment. A is correct. Rationale: The obturator facilitates immediate tube replacement, critical in the first 72 hours before a tract forms, preventing airway loss, a priority per surgical nursing standards over other less relevant items.
In Virginia Henderson's 1966 definition of nursing, a person/client has which of the following numbers of fundamental needs?
- A. 7
- B. 14
- C. 18
- D. 22
Correct Answer: B
Rationale: Virginia Henderson's 1966 definition identifies 14 fundamental needs that nursing addresses to help clients achieve independence or a peaceful death. These include breathing, eating, elimination, and rest, among others, forming a comprehensive framework for holistic care. Unlike narrower or broader counts, 14 captures the essentials Henderson deemed universal, guiding nurses to assess and support each area. For example, assisting a client with mobility meets one need, while ensuring nutrition meets another, illustrating practical application. This specificity distinguishes her model, balancing detail with practicality in nursing practice.
Which of the following statement best describe advocacy in nursing?
- A. Ignoring patient wishes
- B. Protecting patient rights
- C. A routine task
- D. A medical diagnosis
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.