Nokea
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Autonomy
- C. Beneficence
- D. Justice
Correct Answer: A
Rationale: The correct answer is A: Fidelity. Fidelity in nursing ethics involves keeping promises and being faithful to commitments, demonstrating reliability and trustworthiness. In this scenario, the nurse is exemplifying fidelity by returning promptly to the client as promised. Choice B, Autonomy, refers to respecting a patient's right to make their own decisions, not relevant in this situation. Choice C, Beneficence, involves the duty to act in the best interest of the patient, which is not the primary focus here. Choice D, Justice, pertains to fairness and equity in the distribution of healthcare resources, not applicable to the nurse's actions in this case.
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A client reports increased pain following physical therapy. Which of the following questions should be asked to assess the quality of the pain?
- A. Is your pain sharp or dull?
- B. Is your pain constant or intermittent?
- C. On a scale from 1 to 10, how severe is your pain?
- D. Where exactly is your pain located?
Correct Answer: A
Rationale: Correct Answer: A. Asking whether the pain is sharp or dull helps in determining the quality of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate chronic issues. Choices B, C, and D focus on different aspects of pain assessment. Option B pertains to the pattern of pain, either constant or intermittent. Option C addresses the severity of pain on a numerical scale. Option D inquires about the location of pain. While all these questions are essential in pain assessment, when specifically evaluating the quality of pain, distinguishing between sharp and dull sensations is crucial.
When lifting a bedside cabinet to move it closer to a client who is sitting in a chair, which of the following actions should the nurse take to prevent self-injury?
- A. Bend at the waist
- B. Keep feet close together
- C. Use back muscles for lifting
- D. Stand close to the cabinet when lifting it
Correct Answer: D
Rationale: The correct answer is to stand close to the cabinet when lifting it. This action keeps the object close to the nurse's center of gravity, reducing the risk of back strain. Bending at the waist (Choice A) can increase the risk of back injury as it puts strain on the lower back. Keeping feet close together (Choice B) does not provide a stable base of support for lifting a heavy object. Using back muscles for lifting (Choice C) is incorrect as it can lead to back strain and injury. Therefore, standing close to the cabinet when lifting it is the safest and most effective approach to prevent self-injury.
A healthcare professional is preparing to insert an NG tube for a client admitted with bowel obstruction. Which of the following should the healthcare professional do first?
- A. Explain the procedure to the client
- B. Measure the length of the NG tube
- C. Lubricate the NG tube
- D. Place the client in a high Fowler's position
Correct Answer: A
Rationale: Explaining the procedure to the client is the initial and most important step that the healthcare professional should take before inserting an NG tube. By explaining the procedure, the healthcare professional ensures the client's understanding, obtains informed consent, and fosters cooperation. Measuring the length of the NG tube, lubricating the tube, and positioning the client in a high Fowler's position are essential steps in the NG tube insertion process but should come after the client has been informed and consented to the procedure.
A client has restraints on each extremity. Which of the following assessments should the nurse perform first?
- A. Peripheral pulses
- B. Comfort level
- C. Elimination needs
- D. Skin integrity
Correct Answer: A
Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.
A client has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?
- A. This type of hearing aid allows for fine-tuning of volume.
- B. I should ensure the hearing aid stays secure during exercise.
- C. I might hear a whistling sound when I first insert the hearing aid.
- D. I will be sure to remove my hearing aid before taking a shower.
Correct Answer: D
Rationale: The correct answer is D because removing the hearing aid before taking a shower is essential to prevent water damage, as moisture can harm the device. Choice A is incorrect because behind-the-ear hearing aids do allow for fine-tuning of volume. Choice B is incorrect because exercise may cause the hearing aid to shift position, so it's important to ensure it stays secure. Choice C is incorrect because hearing a whistling sound when inserting the hearing aid may indicate improper placement or fit.