Nokea
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?
- A. Standing at the end of the bed
- B. Standing at the side of the bed
- C. Sitting at least six feet from the bedside
- D. Sitting at a 45-degree angle to the bed
Correct Answer: D
Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (A) limits the nurse's view and communication. Standing at the side of the bed (B) may obstruct the nurse-client interaction. Sitting at least six feet away (C) creates unnecessary distance and hinders effective communication.
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Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client’s situation?
- A. Kardex
- B. Case management
- C. Critical pathways
- D. Concept map care plan
Correct Answer: D
Rationale: The correct answer is D: Concept map care plan. This type of care plan allows the nurse to visually represent the client's entire situation, including physical, emotional, and social aspects. By using interconnected concepts and relationships, the nurse can see the whole picture and identify potential interventions. Kardex (A) is a concise patient information summary, not comprehensive. Case management (B) focuses on coordinating services but may not capture the holistic view. Critical pathways (C) outline specific steps in care but may not address the client as a whole.
A patient was rushed to the ER because of difficulty in urination. He was diagnosed then as a cse of benign prostate hyperthropy (BPH) and was advised by the doctor to undego transurethral resection of prostate (TURP). Based on the urgency of the surgery, the nurse classifies this condition as:
- A. emergency
- B. C.urgent
- C. elective
- D. required
Correct Answer: A
Rationale: The correct answer is A: emergency. In this scenario, the patient is experiencing difficulty in urination due to benign prostate hyperplasia (BPH), a condition that can lead to serious complications like acute urinary retention. Transurethral resection of the prostate (TURP) is a surgical procedure that is used to relieve the obstruction caused by BPH. Given the urgency of the situation and the potential for acute complications, the surgery needs to be performed immediately to prevent further harm to the patient's health. Classifying this condition as an emergency ensures prompt intervention and prioritizes the patient's well-being.
Summary:
- B: C.urgent (not correct): While the surgery is time-sensitive, it does not require immediate intervention like in an emergency situation.
- C: elective (not correct): Elective surgeries are planned in advance and are not typically performed in urgent situations like this one.
- D: required (not correct): While the surgery is necessary for the patient's condition
A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
- A. patients.” “If the nursing department uses this system, communication among nurses who work
- B. throughout the hospital may be enhanced.” “We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our
- C. unit.” “The NIC system provides one way to improve safe and effective documentation in the
- D. hospital’s electronic health record.”
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.
Seven girls were victims of food poisoning after eating the sandwiches served at snack time. Which of the following statement are true regarding food poisoning?
- A. Symptoms include salivation, cramping, nausea, vomiting and diarrhea
- B. Foods that are handled and allowed to remain without refrigeration before eaten are most dangerous
- C. Cooking will destroy the organism and stop production of enterotoxin
- D. All are correct
Correct Answer: D
Rationale: Step 1: Symptoms of food poisoning typically include salivation, cramping, nausea, vomiting, and diarrhea, so statement A is correct.
Step 2: Food left unrefrigerated can lead to bacterial growth, making it more dangerous, so statement B is accurate.
Step 3: Cooking can kill harmful organisms and stop the production of toxins, supporting statement C.
Step 4: All three statements are true and collectively provide a comprehensive understanding of food poisoning, making option D the correct answer.
When can a donor and recipient of blood be considered compatible?
- A. If there is no change in the blood color when both samples are mixed in the laboratory
- B. If there are blood clots when both samples are mixed in the laboratory
- C. If there is no clumping or hemolysis when both samples are mixed in the laboratory
- D. If a blood drop does not sink when dropped in water after both samples are mixed in the laboratory
Correct Answer: C
Rationale: The correct answer is C because compatibility between blood donor and recipient is determined by the absence of clumping or hemolysis when both samples are mixed. Clumping indicates an incompatible blood type reaction, leading to potential harm. Blood clots (option B) are not indicative of compatibility but rather a sign of coagulation issues. Blood color change (option A) and blood drop sinking in water (option D) are not reliable indicators of blood compatibility. In summary, option C is correct as it directly assesses for the absence of a harmful reaction, while the other choices do not accurately determine blood compatibility.