Nokea
On first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of:
- A. aggressiveness.
- B. passive aggressiveness.
- C. passiveness.
- D. assertiveness.
Correct Answer: D
Rationale: This nurse manager is demonstrating assertive behavior. Aggressive behavior dominates or embarrasses. Passive behavior is nervous or timid. Passive-aggressive behavior is dominating or manipulative without directness.
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The hydraulic lift (Hoyer lift) is:
- A. used for all clients who've had orthopedic surgery.
- B. used for all clients who are not able to stand and for extremely obese clients.
- C. used for all clients, both old and young, in a hospital setting.
- D. not an assistive device for special needs.
Correct Answer: B
Rationale: The hydraulic lift is used for safe transfer when a client is not able to stand or is too heavy for the health care workers to lift safely.
A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
- A. standing the client and walking him or her to the wheelchair.
- B. moving the wheelchair close to client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
- C. moving the wheelchair close to client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
- D. having the client stand and push his body to the wheelchair.
Correct Answer: B
Rationale: Moving the wheelchair close to client's bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.
The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?
- A. Ask the client to recall at the end of the day the food and beverages consumed.
- B. Inform the client how to count the calories in the food and beverages consumed.
- C. Inform the client that a record will be maintained of food and beverages consumed.
- D. Ask the client to identify the food groups and foods that are being consumed in each.
Correct Answer: C
Rationale: C: Recording food intake ensures accurate calorie counts. A: Recall is unreliable. B: Clients don't calculate calories in hospital. D: Food groups don't provide calorie data.
A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
- A. Verbal teaching in short sessions throughout the day.
- B. Pre-operative booklet on the surgery in Braille.
- C. Provide a tape for the client.
- D. Have the blind patient's family member instruct the patient.
Correct Answer: A
Rationale: Information is smaller amounts is easier to retain. Teaching the day before the procedure is best accomplished in a one on one format.
The nurse is caring for the 11-month-old infant with bronchopulmonary dysplasia. The infant has 30% supplemental oxygen provided via a tracheostomy. Which action should the nurse take when the infant has a decline in oxygen saturation from 96% to 87% and appears anxious and restless?
- A. Obtain arterial blood gases (ABGs)
- B. Increase oxygen rate from 30% to 50%
- C. Suction the tracheostomy tube
- D. Medicate for anxiety and pain
Correct Answer: C
Rationale: C: Suctioning clears potential airway obstructions causing desaturation. A: ABGs are secondary if suctioning resolves distress. B: Increasing oxygen is ineffective with an occluded airway. D: Medication doesn't address airway issues.