Nokea
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.
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The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning a morphine order for pancreatitis exemplifies the client advocate role, where nurses safeguard patient well-being. Morphine can worsen pancreatitis by causing sphincter of Oddi spasm, unlike safer options like meperidine. By challenging this, the nurse protects the client from harm, a duty rooted in ethical codes like the ANA's. Change agents modify behaviors, case managers coordinate, and collaborators work jointly, but advocacy uniquely prioritizes patient safety over compliance. In practice, this might involve consulting the doctor for an alternative, ensuring care aligns with the patient's best interest, a critical nursing responsibility.
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.
Mr. Gary drinks alcohol to forget his stress. This is an example of?
- A. Adaptive coping
- B. Maladaptive coping
- C. Health promotion
- D. Wellness
Correct Answer: B
Rationale: Drinking to forget stress is maladaptive coping (B) ineffective, harmful, per Lazarus (e.g., addiction risk). Adaptive (A) helps, health promotion (C) enhances, wellness (D) state not coping type. B fits short-term escape, making it correct.
Mr. Gary refuses pork-based medication because of his religious belief. This is an example of?
- A. Culture
- B. Illness
- C. Disability
- D. Risk factor
Correct Answer: A
Rationale: Refusing pork-based meds due to religion is culture (A) beliefs shaping health choices, per cultural competence. Illness (B) is disease, disability (C) function loss, risk factor (D) predisposition not belief-based. A reflects how culture influences care decisions, making it correct.
Which of the following statement best describe implementation in nursing process?
- A. Identifying problems
- B. Setting goals
- C. Carrying out interventions
- D. Evaluating outcomes
Correct Answer: C
Rationale: Implementation is carrying out interventions (C), per nursing process e.g., giving meds. Not identifying (A), setting (B), evaluating (D) action-focused. C best defines implementation's execution, making it correct.