Nokea
The nurse asked an aide to check Mr. Gary's vitals. This is an example of?
- A. Delegation
- B. Responsibility
- C. Malpractice
- D. Health policy
Correct Answer: A
Rationale: Asking an aide for vitals is delegation (A) task assignment, per definition. Responsibility (B) duty, malpractice (C) breach, policy (D) rules not delegation-specific. A fits the nurse's supervised task for Mr. Gary, making it correct.
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The nurse is caring for a client following a transurethral resection of the prostate (TURP). Which finding should be reported to the physician immediately?
- A. Bright red urine 12 hours post-op
- B. Urine output of 30 mL/hour
- C. Complaints of bladder spasms
- D. Temperature of 100.2°F
Correct Answer: A
Rationale: Bright red urine 12 hours post-TURP suggests active bleeding, abnormal beyond initial pink-tinged output, requiring immediate physician report low output, spasms, or mild fever are less urgent. Nurses flag this, as hemorrhage risks clot retention or shock, prompting irrigation or intervention.
Which of the following assessment finding is typical of extracellular fluid loss?
- A. Distended jugular veins
- B. Elevated hematocrit level
- C. Rapid thready pulse
- D. Increased serum sodium level
Correct Answer: C
Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.
A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
- A. Host
- B. Agent
- C. Environment
- D. Disease
Correct Answer: B
Rationale: In the Agent-Host-Environment Model, Staphylococcus is the agent the causative factor triggering illness, here infecting a decubitus ulcer. The client is the host, whose skin integrity and immunity determine susceptibility. The environment bedridden conditions or hygiene sets the stage for infection. The disease is the resulting pathology, like the ulcer's worsening. This model dissects causation: Staphylococcus (bacteria) invades the host (client) in a conducive environment (immobility), driving nursing interventions cleaning wounds, repositioning to disrupt the triad. Understanding the agent's role guides targeted care, like antibiotics, breaking the infection cycle. It's a practical lens for nurses, pinpointing external triggers to prevent or manage illness effectively, especially in chronic wound scenarios.
The parents of a healthy 6-year-old ask the nurse for advice about preventing obesity in their child. Which response reflects health promotion?
- A. Limit screen time and encourage outdoor play.'
- B. Weigh your child monthly to monitor for weight gain.'
- C. Give your child a multivitamin daily to prevent obesity.'
- D. Have your child's cholesterol checked annually.'
Correct Answer: A
Rationale: For a healthy 6-year-old, health promotion prevents obesity by fostering active habits limiting screen time and encouraging outdoor play boosts physical activity, burning calories and building muscle, key to avoiding weight gain at this age. Evidence links sedentary screen hours to childhood obesity; play counters it, aligning with nursing's focus on lifestyle over surveillance. Monthly weighing is secondary, tracking not preventing, and may stress the child. Multivitamins don't prevent obesity caloric balance does while annual cholesterol checks detect, not avert, issues. The nurse's reply promotes wellness through fun, practical steps like biking or tag tailored to a child's energy, ensuring long-term health without medicalizing a well kid, a cornerstone of pediatric nursing's preventive approach.
A patient develops red eyes 2 days after an episode of malaria probable cause is:
- A. Conjunctivitis
- B. Anterior uveitis
- C. Viral keratitis
- D. Endophthalmitis
Correct Answer: B
Rationale: Red eyes post-malaria suggest an ocular complication. Conjunctivitis (choice A) causes redness but isn't typically linked to malaria unless secondary infection occurs. Anterior uveitis (choice B), inflammation of the iris and ciliary body, is a rare but documented malaria sequel, possibly from immune response or parasite-related damage, presenting with redness, pain, and photophobia. Viral keratitis (choice C) affects the cornea and is unrelated to malaria. Endophthalmitis (choice D), a severe intraocular infection, is unlikely without trauma or surgery. B is correct, as anterior uveitis aligns with malaria's systemic inflammatory effects. Nurses should assess eye symptoms, refer to ophthalmology, and manage pain, preventing vision loss in such cases.