Nokea
How often should the nurse change the intravenous tubing on total parenteral nutrition solutions?
- A. every 24 hours
- B. every 36 hours
- C. every 48 hours
- D. every 72 hours
Correct Answer: A
Rationale: The nurse should change the intravenous tubing on total parenteral nutrition solutions every 24 hours, due to the high risk of bacterial growth.
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A concern regarding maternal and infant mortality and morbidity is that:
- A. a segment of the population is not receiving prenatal care.
- B. families appear unconcerned about quality health care.
- C. the personnel shortage in the maternity field will increase.
- D. maternal-child health workers are not adequately prepared.
Correct Answer: A
Rationale: There is a concern that a segment of the population is not accessing prenatal care, affecting infant and maternal mortality and morbidity.
Which of these would be the most appropriate way to document a client's refusal of medication?
- A. Heparin refused during shift. Risks reviewed.'
- B. The client refused the heparin injection when I tried to administer it. She yelled at me saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift.'
- C. Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client and client verbalized understanding.'
- D. Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct and ct verbalized understanding.'
Correct Answer: C
Rationale: Documentation in healthcare should be objective, thorough, but direct. It should be articulate, with correct grammar and spelling.
A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct Answer: D
Rationale: Counting five blocks demonstrates conservation, the understanding that quantity remains constant despite changes in arrangement or appearance.
The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:
- A. request that the family wait for its loved one in the client's room and wait to resume the report until the family has left the desk area.
- B. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report.
- C. request that the family have a seat in the station rather than stand while awaiting its loved one.
- D. request that the family wait for its loved one in the Emergency Department waiting room.
Correct Answer: A
Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room, and the report should be resumed only after it can no longer hear what is said.
Which of the following nursing actions is most effective when evaluating a kinetic family drawing?
- A. telling the child to draw their family doing something
- B. offering specific suggestions of what to include in the drawing
- C. discouraging the child from talking about the drawing
- D. noting the omission of any family members
Correct Answer: D
Rationale: There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing actions include asking the client to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.