Nokea
A client with pneumonia exhibits signs of respiratory distress and decreased oxygen saturation. What is the primary indication for initiating oxygen therapy in this client?
- A. Promoting lung expansion
- B. Enhancing antimicrobial therapy
- C. Improving oxygen delivery to tissues
- D. Reducing the risk of bacterial resistance
Correct Answer: C
Rationale: Improving oxygen delivery to tissues (C) is the primary indication for oxygen therapy in pneumonia with distress and low SpO2, correcting hypoxia from impaired gas exchange. Lung expansion (A) is secondary. Antimicrobial therapy (B) treats infection, not oxygenation. Bacterial resistance (D) is unrelated. Enhanced oxygen delivery supports vital organs, per infectious disease care principles, critical in acute respiratory compromise.
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When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
- A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
- B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
- C. The chart is a legal document and may be all a nurse has to support care that was given if called to court.
- D. Clients need to be assessed and the care documented at least once every hour during the shift.
Correct Answer: C
Rationale: Documentation is a cornerstone of nursing practice, and recognizing the chart as a legal document is paramount. It serves as the primary evidence of care provided, protecting the nurse in legal disputes by detailing actions, observations, and client responses. If called to court, this record may be the only defense against claims of negligence or improper care, making accuracy and completeness essential. Brevity might compromise detail, undermining its legal value, while specific formats like SOAP enhance clarity but aren't the core issue. Hourly documentation isn't universally required unless specified by policy; the focus is on capturing significant events. This understanding ensures nurses document with precision, safeguarding both client care and professional accountability in a legal context.
The most important nursing intervention to correct skin dryness is:
- A. Avoid bathing the patient until the condition is remedied, and notify the physician
- B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
- C. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection
- D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas
Correct Answer: D
Rationale: Hydration, gentle soap, and lotion address dryness and prevent cracking.
The nurse administers cleansing enema. The common position for this procedure is...
- A. Sims left lateral
- B. Dorsal Recumbent
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sims left lateral allows easy access to the rectum and comfort during an enema.
When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?
- A. whoever is authorized by hospital policy
- B. the student nurse giving the client's care
- C. the student nurse's instructor
- D. any licensed nurse on duty
Correct Answer: A
Rationale: Hospital policy dictates who takes telephone orders, ensuring legal and safety compliance, typically a licensed nurse, not a student or instructor alone. This standard protects clients from errors by untrained personnel, aligning with nursing scope and institutional rules for accurate order execution.
Which of the following statement is NOT true about crisis intervention?
- A. Aims to restore pre-crisis state
- B. Short term
- C. Requires long term therapy
- D. Focuses on immediate needs
Correct Answer: C
Rationale: Crisis intervention restores pre-crisis (A), is short-term (B), immediate-focused (D) 'requires long-term therapy' (C) isn't true, as it's brief, per Caplan. C's duration contradicts, making it untrue.