A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?
- A. Insert the rectal tube 15.2 cm (6 inches) into the client's rectum
- B. Wear clean gloves before inserting the tubing
- C. Position the client on their left side
- D. Hold the solution bag 91 cm (36 inches) above the client's rectum
Correct Answer: C
Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.
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The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should:
- A. Record the heart rate and call the physician
- B. Record the heart rate and administer the medication
- C. Administer the medication and recheck the heart rate in 15 minutes
- D. Hold the medication and recheck the heart rate in 30 minutes
Correct Answer: B
Rationale: For a 6-month-old, an apical pulse of 100 beats per minute falls within the normal range (80-150 bpm), indicating it's safe to administer digoxin, a cardiac glycoside for heart defects, without delay. Recording and calling the physician or holding the dose isn't warranted unless the rate drops below 90-100 bpm (per pediatric guidelines). Rechecking post-administration isn't standard unless symptoms arise. Nurses document and proceed, ensuring timely therapy while monitoring for toxicity signs like bradycardia later.
Which of the following statement best describe a health belief model?
- A. Explains why people get sick
- B. Explains health behavior based on belief
- C. Focuses on disease treatment
- D. Based on medical diagnosis
Correct Answer: B
Rationale: Health belief model explains health behavior via beliefs (B), per theory e.g., perceived risk drives action. Sickness (A) and treatment (C) aren't focus, diagnosis (D) medical. B best defines HBM's psychological basis, making it correct.
Which of the following statement best describe the resistance stage of GAS?
- A. Body shuts down due to stress
- B. Body adapts to stress
- C. Immediate reaction to stress
- D. Permanent damage occurs
Correct Answer: B
Rationale: Resistance stage is body adapting to stress (B), per GAS sustaining effort (e.g., cortisol stabilizes). Shutdown (A) and damage (D) are exhaustion, immediate (C) alarm. B best defines resistance's coping phase, making it correct.
A client with ulcerative colitis is receiving dietary management education from a healthcare provider. Which statement by the client indicates an understanding of the teaching?
- A. I should increase my intake of dairy products.
- B. I should decrease my intake of dairy products.
- C. I should increase my intake of high-fiber foods.
- D. I should decrease my intake of high-fat foods.
Correct Answer: B
Rationale: The correct answer is B because reducing dairy product intake can help manage symptoms of ulcerative colitis. Dairy products can exacerbate symptoms in some individuals due to their lactose content and may need to be limited or avoided based on individual tolerance levels. Choice A is incorrect because increasing dairy products can worsen symptoms for some ulcerative colitis patients. Choice C is incorrect as while high-fiber foods are generally beneficial, they may exacerbate symptoms during a flare-up. Choice D is also incorrect as while reducing high-fat foods can be beneficial, dairy products are a more specific concern for ulcerative colitis.
Which are goals of nursing theory?
- A. Provide knowledge and a rationale for client interventions
- B. Provide a rationale for appropriate nursing actions in a given situation
- C. Identify and define concepts that are important to nursing
- D. Provide a definition for nursing
Correct Answer: A
Rationale: Nursing theory serves as a foundational framework, guiding practice with clear goals. It provides knowledge and a rationale for client interventions, explaining why specific actions like wound care techniques benefit patients, rooted in conceptual understanding. It offers a rationale for appropriate nursing actions, ensuring responses to situations, such as pain management, are logical and effective. Identifying and defining concepts important to nursing like health or caring clarifies the discipline's focus, fostering consistency. Increasing the nursing body of knowledge expands its intellectual base through theoretical development. However, it doesn't provide a single definition for nursing, instead directing it toward a common purpose across diverse interpretations. These goals unify nursing, bridging theory to practice, and equip nurses to deliver informed, purposeful care that adapts to client needs and evolves with new insights.