Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Compliance or performance at the minimally acceptable level is not considered quality care.
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The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?
- A. Nasogastric tube to low intermittent suction has small amounts of dark bloody returns.
- B. Oxygen saturation level is 92%, and oxygen by nasal cannula is set at 2 liters.
- C. The incisional dressing has a 25-cent-piece-sized shadow of new drainage.
- D. The Jackson-Pratt drain is round in shape with 30 mL serosanguineous drainage.
Correct Answer: D
Rationale: D: A round JP drain indicates lost suction, requiring immediate emptying and compression. A: Minor bloody NG returns are normal post-surgery. B: 92% saturation is adequate. C: Small drainage is monitorable.
A client has a nasogastric (NG) tube in place following abdominal surgery. The purpose of this tube immediately following surgery is to:
- A. simplify medication administration
- B. measure accurate input and output
- C. prevent accumulation of fluids and gas
- D. facilitate collection of specimens
Correct Answer: C
Rationale: Postoperative NG tubes decompress the stomach, preventing fluid and gas buildup that could disrupt surgical sites or cause vomiting.
The nurse learns at shift report that the immobile client has bilateral foot drop. Which finding during the nurse's assessment supports the presence of foot drop?
- A. The client's great toe is dorsiflexed, and the other toes are fanned out.
- B. The client's feet are unable to be maintained perpendicular to the legs.
- C. The client is unable to move the feet into a position of plantar flexion.
- D. The client is only able to dorsiflex both feet when asked to bend the feet.
Correct Answer: B
Rationale: B: Inability to hold feet perpendicular indicates foot drop. A: This describes a Babinski sign. C: Foot drop involves persistent plantar flexion, not inability to plantar flex. D: Foot drop prevents dorsiflexion.
The nurse is using a hypothermia blanket for the febrile client. Which findings should prompt the nurse to consider that the client is hypothermic? Select all that apply.
- A. Increased urine output
- B. Increased drowsiness
- C. Decreased heart rate (HR)
- D. Decreased blood pressure (BP)
- E. Increased core body temperature
Correct Answer: B,C,D
Rationale: B: Drowsiness results from low cardiac output affecting the CNS. C: Decreased HR reflects thermoregulation effects. D: Decreased BP reduces cardiac workload. A: Hypothermia decreases urine output. E: Hypothermia lowers core temperature.
Nonpharmacological pain management involves all of the following except:
- A. hypnosis alone.
- B. psychological care, including support groups.
- C. physical and psychological modalities.
- D. pain-reducing drugs only.
Correct Answer: D
Rationale: All physical and psychosocial therapies can be used concurrently with drugs and other modalities to manage pain. These interventions can be carried out by the nurse with the client and family.
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