Nokea
How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?
- A. 5
- B. 10
- C. 15
- D. 30
Correct Answer: D
Rationale: After activity, smoking, or caffeine e.g., raising BP 30 minutes rest ensures accuracy, per AHA guidelines. Shorter times (5-15 min) risk false highs. Nurses enforce this e.g., post-exercise delay for reliable readings, standard in clinical assessment protocols.
You may also like to solve these questions
Which of the following statement is TRUE about safety in health care?
- A. Errors are unavoidable
- B. Focuses on preventing harm
- C. Only applies to surgery
- D. All of the above
Correct Answer: B
Rationale: Safety focuses on preventing harm (B), per standards e.g., protocols reduce risks. Errors can be minimized (A), not surgery-only (C), not all (D) broad scope. B truly defines safety's priority, making it correct.
Founder of the PNA
- A. Julita Sotejo
- B. Anastacia Giron Tupas
- C. Eufemia Octaviano
- D. Anesia Dionisio
Correct Answer: B
Rationale: Anastacia Giron-Tupas founded the Philippine Nurses Association in 1922, advancing Filipino nursing's professional status e.g., advocating licensure. Sotejo, Octaviano, and Dionisio contributed differently. Her leadership at PGH and PNA shaped national standards, a key historical milestone in local nursing.
The nurse is preparing a client with gout for discharge. Which dietary selection reflects an understanding of the client's condition?
- A. Broiled chicken, rice, and iced tea
- B. Sardines, lima beans, and red wine
- C. Hamburger, fries, and a milkshake
- D. Shrimp, spinach, and beer
Correct Answer: A
Rationale: Broiled chicken, rice, and iced tea suit gout, avoiding purine-rich foods (sardines, shrimp) or alcohol (wine, beer) that raise uric acid lima beans and spinach also contribute less but aren't ideal. Nurses teach this, reducing flare-ups, supporting joint health and client compliance.
An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?
- A. Perform physical assessment
- B. Have the client rate his pain on the smiley pain rating scale
- C. Active listening on what the patient says
- D. Observe the client's behavior
Correct Answer: B
Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.
The nurse is caring for a client with a diagnosis of cirrhosis who has developed esophageal varices. Which of the following foods should be removed from the client's diet?
- A. Custard
- B. Mashed potatoes
- C. Spinach
- D. Raisins
Correct Answer: C
Rationale: Spinach should be removed from the diet of a client with cirrhosis and esophageal varices, as its rough texture and high vitamin K content could irritate fragile varices or alter clotting, risking rupture and hemorrhage a critical concern in advanced liver disease. Custard, mashed potatoes, and raisins are softer and safer, lacking this risk. Nurses adjust diets to minimize esophageal trauma, teaching clients to avoid coarse foods, protecting against bleeding episodes that could require urgent interventions like banding or transfusion.