Nokea
A client is discussing the use of herbal supplements for health promotion with a nurse. Which of the following client statements indicates an understanding of herbal supplement use?
- A. I can take echinacea to improve my immune system.
- B. I can take feverfew to reduce my level of anxiety.
- C. I can take ginger to improve my memory.
- D. I can take ginkgo biloba to relieve nausea.
Correct Answer: D
Rationale: The correct answer is D because ginkgo biloba is commonly used to improve memory and cognitive function, not to relieve nausea. Echinacea is known for immune support (A), feverfew for migraine prevention (B), and ginger for nausea relief (C). Understanding the intended use of each herb is crucial for safe and effective supplementation.
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Which of the following actions best demonstrates effective delegation by a nurse manager?
- A. Retaining all tasks
- B. Assigning tasks without supervision
- C. Delegating tasks and providing oversight
- D. Avoiding delegation
Correct Answer: C
Rationale: The correct answer is C because effective delegation involves assigning tasks to appropriate staff members while providing oversight. This ensures tasks are completed safely and accurately. Retaining all tasks (A) does not promote staff development. Assigning tasks without supervision (B) can lead to errors. Avoiding delegation (D) limits staff growth. Effective delegation (C) maximizes efficiency and empowers staff.
During a home safety assessment, a nurse is evaluating a client who is receiving supplemental oxygen. Which observation should the nurse identify as a proper safety protocol?
- A. The client has a weekly inspection checklist for oxygen equipment.
- B. The client stores an extra oxygen tank on its side under their bed.
- C. The client identifies the location of a fire extinguisher.
- D. The client uses a wool blanket on their bed.
Correct Answer: A
Rationale: The correct answer is A because having a weekly inspection checklist for oxygen equipment ensures the client is monitoring the equipment regularly for safety. Choice B is incorrect as storing an oxygen tank on its side can be dangerous. Choice C is not directly related to oxygen safety. Choice D is incorrect because wool blankets can create static electricity, which is a fire hazard.
A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, 'Every time you change my bandage, it hurts so much.' Which of the following interventions is the nurse's priority action?
- A. Encourage the client to relax and take deep breaths during the dressing change
- B. Educate the client about the importance of the dressing change to prevent infection
- C. Administer pain medication 45 minutes before changing the client's dressing
- D. Assist the client to a comfortable position for the dressing change
Correct Answer: C
Rationale: The correct answer is C: Administer pain medication 45 minutes before changing the client's dressing. This is the priority action because it directly addresses the client's pain during the dressing change, ensuring their comfort and adherence to the procedure. Administering pain medication in advance allows time for it to take effect, minimizing the discomfort experienced by the client. Encouraging relaxation techniques (A) and educating about the importance of dressing change (B) are important but secondary to addressing the immediate pain issue. Assisting the client to a comfortable position (D) is helpful but does not directly alleviate the pain like pain medication does.
What is the main purpose of a clinical audit?
- A. To measure patient satisfaction
- B. To evaluate the effectiveness of clinical practices
- C. To identify areas for improvement
- D. To standardize patient care protocols
Correct Answer: C
Rationale: The main purpose of a clinical audit is to identify areas for improvement. This involves reviewing current practices, identifying gaps or inefficiencies, and implementing changes to enhance the quality of patient care. Patient satisfaction (A) is important but not the primary goal of a clinical audit. Evaluating the effectiveness of clinical practices (B) may be a part of the audit process, but not the main purpose. Standardizing patient care protocols (D) is beneficial but is not the primary aim of a clinical audit, which focuses on continuous quality improvement.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrists before applying the restraints.
- B. Evaluate the client's circulation every 8 hours after application.
- C. Secure the restraint ties to the bed's side rails.
- D. Remove the restraints every 4 hours to evaluate the client's status.
Correct Answer: C
Rationale: The correct answer is C: Secure the restraint ties to the bed's side rails. This is important for ensuring the client's safety and preventing harm. Attaching the restraints to the side rails allows for proper immobilization without causing injury or restricting circulation. Padding the client's wrists (choice A) can be uncomfortable and ineffective. Evaluating circulation every 8 hours (choice B) is not frequent enough for monitoring potential issues. Removing restraints every 4 hours (choice D) can increase the risk of injury and should only be done as necessary.