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A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
- A. Writing down all assignments
- B. Making changes after evaluating the situation and having discussions with the staff
- C. Telling the staff nurses that she is making changes to benefit their performance
- D. Evaluating the clinical performance of each staff nurse in a private conference
Correct Answer: B
Rationale: Evaluating and discussing changes eases transition and builds trust.
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The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion loosen mucus in cystic fibrosis, creating vibrations without pain, a key physiotherapy technique to clear airways. Heel strikes are harsh, frequent repositioning isn't routine, and post-meal percussion risks reflux. Nurses teach this method for effective secretion management, improving breathing and reducing infection risk in this chronic condition.
A nurse working in a community health center is focusing on illness prevention for a group of young adults. Which action reflects primary prevention?
- A. Screening for sexually transmitted infections
- B. Educating about the risks of smoking
- C. Referring clients with depression to a counselor
- D. Planning care for clients with asthma
Correct Answer: B
Rationale: Primary prevention targets illness before it strikes, ideal for young adults shaping lifelong habits. Educating about smoking risks cancer, lung damage aims to deter uptake or prompt quitting, a modifiable behavior with huge impact, as smoking's a top preventable death cause. Screening for STIs is secondary, catching disease early, not stopping it. Referring depression cases or planning asthma care is tertiary, managing conditions, not preventing onset. Smoking education fits primary prevention's proactive core studies show early awareness cuts initiation rates perfect for a community setting where young adults face peer pressures. Nursing uses this to shift trajectories, reducing chronic illness odds through informed choice, a powerful, scalable action for this age group's health future.
The nurse double-checked Mr. Gary's meds to avoid mistakes. This is an example of?
- A. Safety
- B. Quality improvement
- C. Patient-centered care
- D. Telemedicine
Correct Answer: A
Rationale: Double-checking meds is safety (A) preventing harm, per care standards. QI (B) enhances, patient-centered (C) tailors, telemedicine (D) remote not error-specific. A fits safety's focus, making it correct.
The nurse is caring for a client who sustained a traumatic brain injury. Which intervention should the nurse perform to prevent an increase in intracranial pressure (ICP)?
- A. Suction the client every hour
- B. Maintain the head of the bed at 30 degrees
- C. Encourage the client to cough frequently
- D. Administer a bolus of intravenous fluids
Correct Answer: B
Rationale: Maintaining HOB at 30 degrees (B) reduces ICP by aiding venous drainage. Hourly suctioning (A) or coughing (C) raises ICP. Fluid bolus (D) may worsen it. B is correct. Rationale: Elevation optimizes cerebral perfusion pressure while minimizing ICP, per brain injury care standards, unlike actions that increase intrathoracic pressure.
All of the following are purpose of inflammation except
- A. Increase heat, thereby produce abatement of phagocytosis
- B. Localized tissue injury by increasing capillary permeability
- C. Protect the issue from injury by producing pain
- D. Prepare for tissue repair
Correct Answer: A
Rationale: Inflammation aims to protect and heal tissue, not hinder it. Increasing heat (A) enhances phagocytosis by boosting immune cell activity, not abating it, making this statement incorrect and the exception. Localized injury response (B) occurs as capillary permeability increases, delivering immune cells to the site. Pain (C) protects by discouraging movement, aiding healing. Preparing for tissue repair (D) is a key goal as inflammation clears debris and initiates recovery. The misstatement in A reverses the biological role of heat, which supports immune function rather than suppressing it, confirming A as the answer since it does not align with inflammation's purposes.