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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The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: All are critical to monitor bleeding risks and heparin efficacy.
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
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.
An infant with Tetralogy of Fallot is discharged with a prescription for Lanoxin elixir. The nurse should instruct the mother to:
- A. Administer the medication using a nipple
- B. Administer the medication using the calibrated dropper in the bottle
- C. Administer the medication using a plastic baby spoon
- D. Administer the medication in a baby bottle with 1oz of water
Correct Answer: B
Rationale: Using the calibrated dropper ensures accurate dosing of Lanoxin (digoxin) elixir for an infant with Tetralogy of Fallot, critical due to its narrow therapeutic range and cardiac effects. Nipples, spoons, or dilution in bottles risk under- or overdosing. Nurses teach this method to parents, stressing precision to manage heart defects safely, preventing toxicity or inefficacy.
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.