Nokea
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.
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Which of the following nursing intervention is appropriate when an IV infusion infiltrates?
- A. Elevate the site
- B. Discontinue the infusion
- C. Attempt to flush the tube
- D. Apply warm, moist compress
Correct Answer: B
Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.
The nurse ensured Mr. Gary's meds were given on time. This is an example of?
- A. Responsibility
- B. Accountability
- C. Health literacy
- D. Care coordination
Correct Answer: A
Rationale: Ensuring timely meds is responsibility (A) task duty, per definition. Accountability (B) answerability, literacy (C) understanding, coordination (D) organization not task-specific. A fits the nurse's obligation to Mr. Gary, making it correct.
Which of the following statement best describe quality improvement?
- A. A one-time fix
- B. Ongoing effort to enhance care
- C. A punishment for errors
- D. A financial strategy
Correct Answer: B
Rationale: Quality improvement is an ongoing effort to enhance care (B), per QI models e.g., PDSA cycles. Not one-time (A), not punishment (C), not just finance (D) continuous. B best defines QI's iterative nature, making it correct.
Anaphylactic reaction after administering penicillin indicates
- A. An acquired atopic sensitization
- B. Passive immunity to penicillin allergen
- C. Antibodies to penicillin developed after earlier use of the drug
- D. Developed potent bivalent antibodies when the IV administration was started
Correct Answer: C
Rationale: Anaphylaxis is a severe IgE-mediated allergic reaction, occurring when prior penicillin exposure sensitizes the immune system, forming antibodies. Re-exposure triggers histamine release, causing symptoms like shock or dyspnea. Atopic sensitization relates to predisposition, not specific drug history. Passive immunity involves transferred antibodies, not self-developed ones. Bivalent antibodies forming during IV use is incorrect sensitization precedes administration. Nurses must assess allergy history, preparing for emergencies like epinephrine administration to reverse this life-threatening response.
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.