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 nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
- A. The application of moist heat will alter tissue sensitivity by producing numbness.
- B. The application of moist heat will decrease the metabolic needs of the involved tissues.
- C. The application of moist heat will stop the local release of histamine in the tissues.
- D. The application of moist heat will increase blood flow and accelerate tissue healing.
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.
An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. inability to turn, cough, and breathe deeply
- B. inability to communicate pain
- C. inability to ambulate freely
- D. inability to use a bedside commode
Correct Answer: B
Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed at least 30 degrees.
- B. If the residual is greater than 200 mL, the LPN should not administer the enteral feeding.
- C. The residual should be discarded prior to administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct Answer: C
Rationale: The residual should be injected back into the PEG tube, as it contains important enzymes and nutrients.
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.
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.