Nokea
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
- A. Place the probe on the child's abdomen
- B. Recalibrate the oximeter at the beginning of each shift
- C. Apply the probe and wait 15 minutes before obtaining a reading
- D. Place the probe on the child's finger
Correct Answer: D
Rationale: Placing the pulse oximeter probe on the finger ensures an accurate oxygen saturation reading in an 8-year-old, as peripheral sites like fingers provide reliable arterial pulsation data. The abdomen isn't suitable, recalibration isn't routine, and waiting 15 minutes delays care unnecessarily. Nurses use this technique for quick, precise monitoring, critical in respiratory infections to guide oxygen therapy.
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A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
- A. Host
- B. Agent
- C. Environment
- D. Disease
Correct Answer: B
Rationale: In the Agent-Host-Environment Model, Staphylococcus is the agent the causative factor triggering illness, here infecting a decubitus ulcer. The client is the host, whose skin integrity and immunity determine susceptibility. The environment bedridden conditions or hygiene sets the stage for infection. The disease is the resulting pathology, like the ulcer's worsening. This model dissects causation: Staphylococcus (bacteria) invades the host (client) in a conducive environment (immobility), driving nursing interventions cleaning wounds, repositioning to disrupt the triad. Understanding the agent's role guides targeted care, like antibiotics, breaking the infection cycle. It's a practical lens for nurses, pinpointing external triggers to prevent or manage illness effectively, especially in chronic wound scenarios.
Mr. Gary refused chemotherapy even if it will help his condition. The nurse respected his decision. This is an example of?
- A. Autonomy
- B. Beneficence
- C. Justice
- D. Fidelity
Correct Answer: A
Rationale: Respecting Mr. Gary's chemotherapy refusal is autonomy (A), per ethics honoring his choice. Beneficence (B) promotes good, justice (C) fairness, fidelity (D) promises not refusal-based. A aligns with self-rule, making it correct.
What is the term used for a high-pitched musical sound in clients during a respiratory assessment?
- A. Crowing
- B. Wheezing
- C. Stridor
- D. Sigh
Correct Answer: B
Rationale: A high-pitched musical sound during breathing is wheezing, caused by air passing through narrowed airways, often due to asthma, allergies, or obstruction. Stridor is a harsh, high-pitched sound from upper airway obstruction, distinct from wheezing's expiratory nature. Crowing resembles a rooster's call, linked to laryngospasm, not a musical tone. A sigh is a deep breath, not pathological. Wheezing's recognition guides interventions like bronchodilators, addressing underlying inflammation or constriction, crucial for restoring normal respiration and preventing hypoxia.
Which of the following is considered as an example of intentional tort?
- A. Malpractice
- B. Negligence
- C. Breach of duty
- D. False imprisonment
Correct Answer: D
Rationale: False imprisonment, an intentional tort, involves deliberately restricting someone's freedom, like restraining a competent patient against their will. Malpractice and negligence are unintentional torts, stemming from carelessness or failure to meet standards, not intent. Breach of duty is a negligence component, not a standalone tort. In nursing, intentional torts require purposeful action, and false imprisonment risks legal liability, emphasizing patient rights and consent in care delivery.
Which of the following statement is NOT true about cultural competence in nursing?
- A. Respects diversity
- B. Improves care
- C. Forces assimilation
- D. Adapts to patient needs
Correct Answer: C
Rationale: Cultural competence respects diversity (A), improves care (B), adapts (D) 'forces assimilation' (C) isn't true, opposes respect, per standards. C's coercion contradicts competence, like with Mr. Gary's beliefs, making it untrue.