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As a nurse manager, which of the following best describes this function?
- A. Initiate modification on client's lifestyle
- B. Protect client's right
- C. Coordinates the activities of other members of the health team in managing patient care
- D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution
Correct Answer: D
Rationale: A nurse manager's role encompasses planning (vision formulation), organizing (team coordination), directing (training), and controlling (audits), per management theories like Venzon's. This holistic function e.g., setting care standards, training staff, evaluating outcomes ensures quality across a unit, unlike narrower roles like lifestyle change (change agent), rights protection (advocate), or team coordination (case manager). It's a strategic position driving institutional excellence, pivotal in healthcare leadership.
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When charting in the client's record or chart, the nurse most needs to do which one of the following things?
- A. Date and sign each entry.
- B. Chart every two hours.
- C. Use ballpoint pen and not pencil.
- D. Cross out errors so others can't read them.
Correct Answer: A
Rationale: Dating and signing each chart entry is most essential, establishing a legal timeline and accountability for actions. Fixed intervals aren't mandatory, pens ensure permanence but aren't the priority, and crossing out errors risks misinterpretation. This practice validates care, crucial for nursing documentation integrity.
The nurse is aware that the normal frequency of bowel sounds is
- A. 1-5 gurgles/minute
- B. 5-35 gurgles/minute
- C. 35-60 gurgles/minute
- D. 60-100 gurgles/minute
Correct Answer: B
Rationale: Normal bowel sounds are 5-35 gurgles/minute e.g., peristalsis per norms. Less (hypoactive), more (hyperactive) differ. Nurses count e.g., 1 minute for function, per standards.
In what phase of Nurse patient relationship does a nurse review the client's medical records thereby learning as much as possible about the client?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: A
Rationale: In the Pre-Orientation phase (A), the nurse reviews records to gather data about the client before meeting, preparing for interaction. Orientation (B) begins with the first encounter, building trust. Working (C) involves goal-focused collaboration, and Termination (D) ends the relationship. Pre-Orientation is distinct as it's preparatory, not interactive, aligning with Peplau's model where understanding the client starts pre-contact, making A correct.
The nurse is caring for a client following a right total hip replacement. Which action by the nurse will help prevent dislocation of the prosthesis?
- A. Keeping the client's knees together at all times
- B. Placing the client in a supine position with the legs extended
- C. Placing a pillow between the client's legs when turning
- D. Encouraging the client to use the trapeze to pull himself up in bed
Correct Answer: C
Rationale: Placing a pillow between the legs during turning maintains abduction, preventing hip prosthesis dislocation post-right total hip replacement knees together adducts, supine extension risks posterior dislocation, and trapeze use is safe but unrelated. Nurses enforce this, ensuring joint stability, key for orthopedic recovery.
Which of the following statement is NOT true about nonmaleficence?
- A. Avoiding harm
- B. Part of nursing ethics
- C. Always prevents all harm
- D. Applies to all actions
Correct Answer: C
Rationale: Nonmaleficence avoids harm (A), is ethical (B), applies broadly (D) 'always prevents all harm' (C) isn't true, as some harm (e.g., injections) is unavoidable, per ethics. It aims to minimize, not eliminate, harm. C's absolute prevention contradicts practical care realities, making it the untrue statement.