Nokea
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.
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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.
When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?
- A. whoever is authorized by hospital policy
- B. the student nurse giving the client's care
- C. the student nurse's instructor
- D. any licensed nurse on duty
Correct Answer: A
Rationale: Hospital policy dictates who takes telephone orders, ensuring legal and safety compliance, typically a licensed nurse, not a student or instructor alone. This standard protects clients from errors by untrained personnel, aligning with nursing scope and institutional rules for accurate order execution.
The nurse is providing dietary instruction for a client with hypoglycemia. To prevent hypoglycemic reactions, the nurse should instruct the client to:
- A. Eat a candy bar if he feels lightheaded
- B. Always carry a quick source of sugar
- C. Limit his intake of fluids with meals
- D. Avoid eating large meals
Correct Answer: B
Rationale: Carrying a quick sugar source (e.g., glucose tabs) prevents hypoglycemic reactions by rapidly raising blood sugar candy is less precise, fluid limits are unrelated, and large meals don't directly cause drops. Nurses teach this, ensuring safety, critical for hypoglycemia management.
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.
Which of the following statement is NOT true about Hospice care?
- A. Offered to terminally ill client
- B. The client's family is included in the care
- C. Focuses on relieving symptoms
- D. Requires client to sign a DNR
Correct Answer: D
Rationale: Hospice cares for terminally ill (A), includes family (B), and relieves symptoms (C), per hospice philosophy. Requiring a DNR (D) isn't true preferred, not mandatory; care focuses on comfort, not resuscitation status. D's absolute requirement misaligns with flexibility, making it the untrue statement.