Nokea
A client with considerable pain asks, 'What is your opinion regarding acupuncture as a drug-free method for alleviating pain?' The nurse responds, 'I'd forget about it as those weird non-Western treatments can be scary.' The nurse's response is an example of
- A. prejudice
- B. discrimination
- C. ethnocentrism
- D. cultural insensitivity
Correct Answer: C
Rationale: Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways, can be a major barrier to providing culturally conscious care.
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Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A. Note subjective data, such as 'My breathing is much improved now.'
- B. Note objective findings, such as decreased respiratory rate and pulse.
- C. Consult with the respiratory therapist to determine effectiveness.
- D. Auscultate the chest for change or clearing of adventitious breath sounds.
Correct Answer: D
Rationale: to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions.
The nurse is reviewing the chart of a 1-day-old infant. Which of the following data requires further action?
- A. Heart rate of 128
- B. Respiratory rate of 72
- C. Hematocrit of 50%
- D. Blood glucose of 60 mg/100 mL
Correct Answer: B
Rationale: A respiratory rate of 72 is elevated for a newborn (normal 30-60 breaths/min), suggesting potential respiratory distress requiring further evaluation.
The mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with:
- A. Gastric lavage
- B. Chelating agents
- C. Antiemetics
- D. Activated charcoal
Correct Answer: B
Rationale: Chelating agents , like succimer, bind lead for excretion. Gastric lavage and charcoal are ineffective for systemic lead. Antiemetics treat symptoms, not the cause.
An adult is admitted through the outpatient department for elective surgery today. The client is coughing and sneezing and has a temperature of 100.6°F. What should the nurse do next?
- A. Prepare the client for surgery as scheduled
- B. Explain to the client that a cold increases risks during surgery and ask if he/she is willing to assume those risks
- C. Call the physician before continuing preparations for surgery
- D. Ask what type of anesthesia the client is receiving
Correct Answer: C
Rationale: Infection increases surgical risks; notifying the physician allows for evaluation and possible postponement.
A six-year-old boy with a history of epilepsy admitted with uncontrolled seizures.
It is MOST important for the nurse to ask which of the following questions?
- A. What part of the body was affected by the seizure?'
- B. What is the family history of seizure disorders?'
- C. What was your son doing before the seizure?'
- D. How long has it been since his last episode of seizures?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates that this is a priority question. (1) not most important question (2) should be included in detailed history, but will not prevent an immediate reoccurrence (3) correct-seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, drugs) (4) should be included in detailed history, but will not prevent an immediate reoccurrence