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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 with limited mobility is at risk for skin breakdown. Which interventions should the nurse include in the plan of care to maintain the client's skin integrity? Select all that apply.
- A. Massage vigorously over bony prominences daily
- B. Wear sterile gloves when inspecting the client's skin
- C. Apply a moisturizing lotion to bony prominences
- D. Instruct the client to change position every 2 hours
- E. Apply an overhead trapeze to the client's bed
- F. Apply a barrier cream if the client is incontinent of stool
Correct Answer: C,D,E,F
Rationale: C: Moisturizers prevent dry skin. D: Repositioning improves circulation. E: Trapezes reduce friction during movement. F: Barrier creams protect against incontinence. A: Vigorous massage causes tissue trauma. B: Sterile gloves are unnecessary unless breakdown exists.
Client room environments should include:
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
- E. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
Correct Answer: B
Rationale: Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.
A nurse is caring for a patient in the step down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
- A. Bradycardia
- B. Increased pupil size bilaterally
- C. Change in LOC
- D. Vomiting
Correct Answer: B
Rationale: Unilateral pupil changes indicate changes in ICP.
When performing an abdominal assessment, what is the correct order of the tasks?
- A. inspect, percuss, palpate, auscultate
- B. inspect, palpate, percuss, auscultate
- C. inspect, auscultate, percuss, palpate
- D. inspect, palpate, auscultate, percuss
Correct Answer: C
Rationale: In an abdominal assessment, percussing or palpating prior to auscultating can alter the bowel sounds and influence findings.
The nurse is observing the UAP providing oral hygiene to the client Which action by the UAP requires follow-up?
- A. Replacing the upper denture before the lower denture.
- B. Placing the unconscious client in a supine position.
- C. Brushing the tongue with a soft-bristled toothbrush.
- D. Donning clean gloves prior to performing oral hygiene.
Correct Answer: B
Rationale: B: The unconscious client should be placed in a side-lying position with the head turned to the side to prevent aspiration. A: Replacing the upper denture first is correct for ease of insertion. C: Brushing the tongue removes debris, reducing infection risk. D: Gloves adhere to standard precautions for oral care.