Nokea
The nurse ensured Mr. Gary's meds were given on time. This is an example of?
- A. Responsibility
- B. Accountability
- C. Health literacy
- D. Care coordination
Correct Answer: A
Rationale: Ensuring timely meds is responsibility (A) task duty, per definition. Accountability (B) answerability, literacy (C) understanding, coordination (D) organization not task-specific. A fits the nurse's obligation to Mr. Gary, making it correct.
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A community health nurse is assessing client's urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?
- A. The nurse added the Urine as the 2/3 part of the solution
- B. The nurse heats the test tube after adding 1/3 part acetic acid
- C. The nurse heats the test tube after adding 2/3 part of Urine
- D. The nurse determines abnormal result if she noticed that the test tube becomes cloudy
Correct Answer: B
Rationale: Acetic acid tests protein cloudiness not glucose; heating only acid (no urine) is wrong. Urine (2/3), heating with urine, cloudiness (protein) are correct. Nurses need correction e.g., purpose for accuracy, per procedure.
While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?
- A. crackles
- B. Rales
- C. adventitious sounds
- D. pleral friction rub
Correct Answer: C
Rationale: Continuous abnormal lung sounds are charted as adventitious, encompassing wheezes or rubs, unlike intermittent crackles or rales. Pleural rub is specific. Nurses document this for respiratory evaluation.
The nurse is caring for a client following a right total hip replacement. Which action by the nurse will help prevent dislocation of the prosthesis?
- A. Keeping the client's knees together at all times
- B. Placing the client in a supine position with the legs extended
- C. Placing a pillow between the client's legs when turning
- D. Encouraging the client to use the trapeze to pull himself up in bed
Correct Answer: C
Rationale: Placing a pillow between the legs during turning maintains abduction, preventing hip prosthesis dislocation post-right total hip replacement knees together adducts, supine extension risks posterior dislocation, and trapeze use is safe but unrelated. Nurses enforce this, ensuring joint stability, key for orthopedic recovery.
The nurse recorded Mr. Gary's vitals in his chart. This is an example of?
- A. Documentation
- B. Standard precautions
- C. Health policy
- D. Patient education
Correct Answer: A
Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.
An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
- A. Stiffness of the right ankle joint
- B. Soreness of the gums
- C. Short-term memory loss
- D. Decreased appetite
Correct Answer: A
Rationale: Joint stiffness signals early contractures or atrophy from immobility.