Nokea
Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse's plan be altered or modified?
- A. halfway through the shift
- B. at the end of the shift before the nurse reports off
- C. when needs change
- D. after the top-priority tasks have been completed
Correct Answer: C
Rationale: The nurse should modify the care plan whenever the client's needs change to ensure responsive and effective care, rather than at fixed times or only after completing tasks.
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Which of the following statements from a client may indicate that they are at a higher risk for a fall?
- A. I would like to get out of bed but would like to put on my non-skid socks first.
- B. Can you make sure the two bedrails are raised before leaving the room?
- C. I think I'm ready to walk a longer distance with the cane today.
- D. I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.
Correct Answer: D
Rationale: A client who is visually impaired without their assistive devices could be at a higher risk for a fall when ambulating.
Which of the following statements indicates that the nurse understands how to promote rest and sleep for the client?
- A. If you would prefer to not be disturbed, we can postpone all vital signs and assessments until tomorrow morning.
- B. With your physical therapy appointments, you cannot nap more during the day even if your sleep is often interrupted at nighttime.
- C. I can try to incorporate any sleep rituals or an ideal bedtime into your routine.
- D. We cannot group together medications, assessments, and other interventions so you may have multiple interruptions at night.
Correct Answer: C
Rationale: To promote rest and sleep, the nurse should try to incorporate any client preferences into the evening routine.
Which of these statements from the caregiver of a palliative care client indicates a proper understanding?
- A. This treatment plan usually means the prognosis is less than 6 months.
- B. We will need to stay in the hospital to receive this level of care.
- C. The main therapeutic goals are comfort and better quality of life.
- D. The medications to treat the underlying disease will be stopped.
Correct Answer: C
Rationale: The goal of palliative care is to make the client as comfortable as possible and not require a hospital stay. Prognoses vary and curative treatments can still be pursued during palliative care.
The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
- A. Wear sterile gloves to remove the lower plate first and then the upper plate.
- B. Use a foam swab to pry the upper and lower plates loose before removing these.
- C. Grasp the upper plate at the front teeth with a piece of gauze and move it prior to removal.
- D. Leave the dentures in the client's mouth and use a toothbrush to brush both denture plates.
Correct Answer: C
Rationale: C: Grasping the upper plate and moving it breaks the suction that holds the plate on the roof of the client's mouth. A: Removing denture plates is a clean procedure, and sterile gloves are not necessary. B: Removing the denture plates with a foam swab to pry the plate could injure the client. D: Dentures must be removed to properly clean the client's mouth and the dentures.
A wrong committed by one person against another (or against the property of another) that might result in a civil trial is:
- A. a tort.
- B. a crime.
- C. a misdemeanor.
- D. a felony.
Correct Answer: A
Rationale: Torts are wrongs committed by one person against another person (or against the property of another), which might result in civil trials. A crime is also defined as a wrong against a person or their property but is considered to be against the public as well. Misdemeanors are crimes that are commonly punishable with fines or imprisonment for less than one year, with both or with parole. A felony is a serious crime punishable by imprisonment in a State or Federal penitentiary for more than one year.