Nokea
The nurse gave pain medication to Mr. Gary even if he did not ask for it because she assessed that he is in pain. This is an example of?
- A. Autonomy
- B. Beneficence
- C. Justice
- D. Fidelity
Correct Answer: B
Rationale: Giving pain meds unasked, based on assessed need, is beneficence (B) doing good, per ethics. Autonomy (A) respects choice, justice (C) fairness, fidelity (D) promises not proactive care. B fits promoting well-being, making it correct.
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Too narrow cuff will cause what change in the Client's BP?
- A. True high reading
- B. True low reading
- C. False high reading
- D. False low reading
Correct Answer: C
Rationale: A narrow cuff e.g., under-sized overcompresses, yielding a false high BP e.g., 140/90 vs. true 120/80. True readings need proper fit; wide cuffs may lower falsely. Nurses select cuffs e.g., per arm size for accuracy, per measurement standards.
The nurse is caring for a client with a closed reduction of the left forearm. Which finding should be reported to the physician immediately?
- A. The client complains of pain at the site of the fracture
- B. The client's fingers are cool and pale
- C. The client's cast has a foul odor
- D. The client's radial pulse is 88 beats per minute
Correct Answer: B
Rationale: Cool, pale fingers post-left forearm closed reduction indicate circulatory compromise, possibly compartment syndrome, needing urgent reporting pain is expected, odor suggests infection (less acute), and pulse (88) is normal. Nurses assess neurovascular status, acting fast, preventing tissue damage in this orthopedic emergency.
The most important nursing intervention to correct skin dryness is:
- A. Avoid bathing the patient until the condition is remedied, and notify the physician
- B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
- C. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection
- D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas
Correct Answer: D
Rationale: Hydration, gentle soap, and lotion address dryness and prevent cracking.
Which of the following is NOT a contraindication in taking ORAL temperature?
- A. Quadriplegic
- B. Presence of NGT
- C. Dyspnea
- D. Nausea and Vomitting
Correct Answer: A
Rationale: Quadriplegia isn't an oral temp contraindication e.g., a paralyzed patient can hold a thermometer if alert. NGT (obstruction), dyspnea (breathing), and nausea (gagging) preclude it. Nurses opt for alternatives e.g., axillary per safety protocols.
The nurse is caring for a client who sustained a traumatic brain injury. Which intervention should the nurse perform to prevent an increase in intracranial pressure (ICP)?
- A. Suction the client every hour
- B. Maintain the head of the bed at 30 degrees
- C. Encourage the client to cough frequently
- D. Administer a bolus of intravenous fluids
Correct Answer: B
Rationale: Maintaining HOB at 30 degrees (B) reduces ICP by aiding venous drainage. Hourly suctioning (A) or coughing (C) raises ICP. Fluid bolus (D) may worsen it. B is correct. Rationale: Elevation optimizes cerebral perfusion pressure while minimizing ICP, per brain injury care standards, unlike actions that increase intrathoracic pressure.