Nokea
A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to
- A. Increase her fluid intake to three liters/day
- B. Request a prescription for a laxative from her physician
- C. Stop taking iron supplements
- D. Take two tablespoons of mineral oil daily
Correct Answer: A
Rationale: Increased fluid intake helps prevent constipation by softening stool.
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Clinitest is used to assess urine for
- A. Protein
- B. Sugar
- C. Phenylketones
- D. Bilirubin
Correct Answer: B
Rationale: Clinitest detects sugar e.g., glucose in diabetes via tablet reaction, unlike acetic (protein), PKU tests (phenylketones), or bilirubin assays. Nurses use e.g., bedside for quick checks, per diagnostics.
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?
- A. Females, after the age 65 tends to have lower BP than males
- B. Disease process like Diabetes increase BP
- C. BP is highest in the morning, and lowest during the night
- D. Africans, have a greater risk of hypertension than Caucasian and Asians.
Correct Answer: A
Rationale: Females over 65 often have higher BP e.g., post-menopause than males, not lower, contradicting Aida's rise. Diabetes (vessel damage), morning peaks (circadian), and African risk (genetics) align. Nurses note this e.g., in elderly diabetics for accurate hypertension management.
The nurse touched Mr. Gary without consent during care. This is an example of?
- A. Battery
- B. Assault
- C. Justice
- D. Nonmaleficence
Correct Answer: A
Rationale: Touching without consent is battery (A) unconsented contact, per law. Assault (B) threat, justice (C) fairness, nonmaleficence (D) harm avoidance not contact-specific. A fits the nurse's breach of Mr. Gary's autonomy, making it correct.
Which of the following statement is TRUE about evaluation in nursing process?
- A. First step of the process
- B. Determines if goals are met
- C. Only done once
- D. All of the above
Correct Answer: B
Rationale: Evaluation determines if goals are met (B), per process e.g., pain reduced? Not first (A, assessment), not once (C, ongoing), not all (D) outcome-focused. B truly defines evaluation's role, making it correct.