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According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
- A. clients (patients)
- B. the profession of nursing
- C. provide high-quality care
- D. all of the above
Correct Answer: D
Rationale: The ANA Code of Ethics encompasses obligations to clients, the nursing profession, and delivering high-quality care, ensuring comprehensive ethical practice.
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The hospitalized client is able to stand to use an electronic digital scale for obtaining the client's prescribed daily weight. Which nursing interventions best ensure that the client's daily weight is accurate? Select all that apply.
- A. Ask the client to wear supportive shoes before stepping on the scale
- B. Ensure that the scale is calibrated and “zeroed†before a weight is obtained
- C. Weigh the client by moving the sliding indicator until the scale balances
- D. Weigh the client at different times of the day and then average the weights
- E. Take the weight as soon as the client wakens in the morning and after voiding
Correct Answer: B,E
Rationale: B: Calibration ensures accuracy. E: Weighing post-voiding at the same time daily standardizes results. A: Shoes add weight. C: Sliding indicators are for balance scales. D: Averaging weights reduces accuracy.
A nurse is assessing a patient's right lower extremity. The extremity is warm to touch, red and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?
- A. Herpes
- B. Scleroderma
- C. Dermatitis
- D. Cellulitis
Correct Answer: D
Rationale: Inflammation of cellular tissue associated with a fever most likely indicates cellulitis.
A hospital discharge planning nurse is making arrangements for a client who has an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?
- A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters
- B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital
- C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility
Correct Answer: B
Rationale: Transferring to a facility unprepared for epidural catheter management risks client safety. Finding a capable facility ensures continuity of care.
The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?
- A. Nasogastric tube to low intermittent suction has small amounts of dark bloody returns.
- B. Oxygen saturation level is 92%, and oxygen by nasal cannula is set at 2 liters.
- C. The incisional dressing has a 25-cent-piece-sized shadow of new drainage.
- D. The Jackson-Pratt drain is round in shape with 30 mL serosanguineous drainage.
Correct Answer: D
Rationale: D: A round JP drain indicates lost suction, requiring immediate emptying and compression. A: Minor bloody NG returns are normal post-surgery. B: 92% saturation is adequate. C: Small drainage is monitorable.
In teaching clients with Buck's Traction, the major areas of importance should be:
- A. nutrition, ROM exercises.
- B. ROM exercises, transportation.
- C. nutrition, elimination, comfort, safety.
- D. elimination, safety, isotonic exercises.
Correct Answer: C
Rationale: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.