Nokea
The nurse adapted care to Mr. Gary's cultural diet. This is an example of?
- A. Cultural competence
- B. Trust
- C. Health promotion
- D. Nursing informatics
Correct Answer: A
Rationale: Adapting to cultural diet is cultural competence (A) diversity respect, per definition. Trust (B) bond, promotion (C) well-being, informatics (D) tech not culture-specific. A fits the nurse's sensitivity to Mr. Gary's needs, making it correct.
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What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
- A. Use sterile gloves when obtaining urine.
- B. Open the drainage bag and pour out the urine.
- C. Disconnect the catheter from the tubing and get urine.
- D. Aspirate urine from the tubing port using a sterile syringe.
Correct Answer: D
Rationale: Aspirating urine from the tubing port with a sterile syringe is the appropriate action for obtaining a sterile urine specimen from an indwelling catheter. This maintains the closed system's integrity, minimizing infection risk by avoiding exposure to external contaminants. The port is designed for sterile sampling, ensuring the specimen reflects bladder contents accurately for testing. Using sterile gloves aids asepsis but isn't the complete action; it supports the procedure, not defines it. Opening the drainage bag introduces bacteria, risking contamination and infection. Disconnecting the catheter breaks the sterile circuit, increasing urinary tract infection likelihood contrary to best practice. Aspiration via the port, paired with aseptic technique, upholds infection control standards, ensuring patient safety and reliable diagnostic results, making it the optimal nursing action.
Which of the following statement is TRUE about palliative care?
- A. Palliative care is given only on Hospice setting
- B. Palliative care is given only to cancer clients
- C. Palliative care improves quality of life
- D. Palliative care is offered only when the client's condition is irreversible
Correct Answer: C
Rationale: Palliative care improves quality of life (C), per its goal managing symptoms, enhancing comfort. It's not hospice-only (A), not cancer-specific (B), and applies beyond irreversible states (D) available at any serious illness stage. C's universal truth aligns with palliative principles, making it correct.
Which of the following statement is TRUE about assault?
- A. Touching the client without consent
- B. An intentional threat
- C. Causes physical harm
- D. All of the above
Correct Answer: B
Rationale: Assault is an intentional threat (B), per law e.g., menacing gesture, no contact needed. Touching (A) is battery, harm (C) not required, all (D) oversteps. B truly defines assault's intent, making it correct.
When examining the client's abdomen, the nurse will most facilitate the examination by positioning the client in which of the following ways?
- A. supine with small pillows beneath knees and head
- B. semi-Fowler's position with knees extended
- C. sitting in the chair with legs elevated
- D. supine with arms extended and hands behind head
Correct Answer: A
Rationale: Supine with pillows under knees and head relaxes abdominal muscles, aiding examination, unlike semi-Fowler's, sitting, or arms-up positions. Nurses use this for effective assessment.
What stress response can you expect from a patient with blood sugar of 50 mg/dl?
- A. Body will try to decrease the glucose level
- B. There will be a halt in release of sex hormones
- C. Client will appear restless
- D. Blood pressure will increase
Correct Answer: C
Rationale: A blood sugar level of 50 mg/dl indicates hypoglycemia, a stress state triggering the body's fight-or-flight response. The client will appear restless due to the brain's reliance on glucose; low levels cause agitation as a protective mechanism to signal distress. The body attempts to increase glucose via glycogenolysis and gluconeogenesis (opposite of A), so decreasing glucose further is incorrect. Halting sex hormone release (B) occurs in chronic stress, not acute hypoglycemia. Blood pressure may rise (D) due to catecholamine release, but restlessness is the most immediate and observable response in this acute scenario, aligning with early stress symptoms. Thus, C is correct as it directly reflects the patient's presentation during a hypoglycemic crisis.