Nokea
The nurse checked if Mr. Gary's pain improved after medication. This is an example of?
- A. Evaluation
- B. Implementation
- C. Assessment
- D. Planning
Correct Answer: A
Rationale: Checking pain improvement is evaluation (A) assessing outcomes, per process. Implementation (B) delivers, assessment (C) gathers, planning (D) sets not outcome-specific. A fits goal review, making it correct.
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Which of the following nursing intervention is appropriate to prevent pulmonary embolus in a patient who is prescribed bed rest?
- A. Limit the client's fluid intake
- B. Encourage deep breathing and coughing
- C. Use the knee gatch when the client is in bed
- D. Teach the patient to move legs in bed
Correct Answer: D
Rationale: Bed rest risks venous stasis, a pulmonary embolus cause. Leg movement promotes circulation, preventing clots from forming and traveling to lungs. Fluid limits dehydration but not emboli directly, deep breathing aids lungs but not veins, and knee gatch increases stasis. Nurses teach exercises, reducing thromboembolism risk, enhancing recovery safety.
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct Answer: B
Rationale: Axillary avoids the oral route post-surgery and is appropriate for a flushed, warm client.
The nurse ensured Mr. Gary's bed rails were up. This is an example of?
- A. Patient safety
- B. Collaboration
- C. Health promotion
- D. Nursing informatics
Correct Answer: A
Rationale: Ensuring bed rails up is patient safety (A) harm prevention, per definition. Collaboration (B) teams, promotion (C) well-being, informatics (D) tech not safety-specific. A fits protective action, making it correct.
A client with pneumonia exhibits signs of respiratory distress and decreased oxygen saturation. What is the primary indication for initiating oxygen therapy in this client?
- A. Promoting lung expansion
- B. Enhancing antimicrobial therapy
- C. Improving oxygen delivery to tissues
- D. Reducing the risk of bacterial resistance
Correct Answer: C
Rationale: Improving oxygen delivery to tissues (C) is the primary indication for oxygen therapy in pneumonia with distress and low SpO2, correcting hypoxia from impaired gas exchange. Lung expansion (A) is secondary. Antimicrobial therapy (B) treats infection, not oxygenation. Bacterial resistance (D) is unrelated. Enhanced oxygen delivery supports vital organs, per infectious disease care principles, critical in acute respiratory compromise.
What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Monitoring I&O ensures fluid balance with hyperosmotic enteral feeding.