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Provides a concise method of organizing and recording data about the client. It is a series of flip cards kept in portable file used in change of shift reports.
- A. Kardex
- B. Progress Notes
- C. SOAPIE
- D. Change of shift report
Correct Answer: A
Rationale: Kardex (A) is a concise, card-based system for shift reports, per nursing practice. Progress notes (B) detail chronologically, SOAPIE (C) structures per problem, shift reports (D) are verbal. A fits the portable file description, making it correct.
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After a week, Mr. Gary's wife said 'If only I insisted an earlier check up, this wouldn't happen' This exemplifies what stage of grieving?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: C
Rationale: If only I insisted is bargaining (C), per Kubler-Ross seeking to undo loss via 'what ifs.' Denial (A) rejects, anger (B) rages, depression (D) despairs. Bargaining reflects guilt-driven deals, making it the correct stage.
A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?
- A. Maintaining oxygen saturation above 95%
- B. Correcting underlying lung pathology
- C. Relieving shortness of breath
- D. Preventing complications of hypoxia
Correct Answer: D
Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.
A client is receiving oxygen therapy via a nasal cannula. What is the appropriate flow rate for this client?
- A. 1-2 liters per minute
- B. 4-6 liters per minute
- C. 8-10 liters per minute
- D. 12-15 liters per minute
Correct Answer: B
Rationale: A flow rate of 4-6 liters per minute (B) is appropriate for nasal cannula oxygen therapy, delivering 36-44% oxygen, suitable for moderate hypoxemia. 1-2 L/min (A) (24-28%) suits mild cases or rest. 8-10 L/min (C) exceeds nasal cannula capacity, causing discomfort. 12-15 L/min (D) is for high-flow systems, not cannulas. This range balances efficacy and tolerance, per respiratory care standards, ensuring adequate oxygenation without nasal irritation.
Which intervention is important in preventing pressure ulcers in immobilized patients?
- A. Frequent repositioning
- B. Encouraging immobility
- C. Maintaining prolonged periods of immobility
- D. Applying tight dressings over bony prominences
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in immobilized patients by relieving pressure on skin over bones, boosting circulation, and reducing tissue breakdown risk. Sustaining or promoting immobility heightens this risk, as does tight dressings that add pressure and impair blood flow. Nurses implement this intervention shifting positions every two hours, for instance to protect skin integrity, a fundamental strategy in caring for those unable to move independently, prioritizing prevention over reactive treatment.
After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH?
- A. Serum osmolality increases
- B. Urine concentration decreases
- C. Glomerular filtration decreases
- D. Tubular reabsorption of water increases
Correct Answer: B
Rationale: ADH deficiency (diabetes insipidus) post-head injury causes dilute urine (B) due to reduced water reabsorption. Osmolality increases (A) is a result, not a cause. GFR (C) isn't primarily affected. Reabsorption (D) decreases. B is correct. Rationale: Low ADH leads to polyuria with low urine concentration, a key assessment in DI, per endocrine trauma care.