Nokea
The nurse is caring for a client following a transurethral resection of the prostate (TURP). Which finding should be reported to the physician immediately?
- A. Bright red urine 12 hours post-op
- B. Urine output of 30 mL/hour
- C. Complaints of bladder spasms
- D. Temperature of 100.2°F
Correct Answer: A
Rationale: Bright red urine 12 hours post-TURP suggests active bleeding, abnormal beyond initial pink-tinged output, requiring immediate physician report low output, spasms, or mild fever are less urgent. Nurses flag this, as hemorrhage risks clot retention or shock, prompting irrigation or intervention.
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Which of the following statement is TRUE about tertiary care?
- A. Provided by general practitioners
- B. Focuses on health promotion
- C. Highly specialized care
- D. All of the above
Correct Answer: C
Rationale: Tertiary care is highly specialized (C), per system e.g., surgery, rehab. Not by GPs (A), not promotion (B), not all (D) advanced focus. C truly defines tertiary's complexity, making it correct.
Which standards are monitored by the Quality and Safety Education for Nurses (QSEN)?
- A. Evidence-based practice
- B. Client-centered care
- C. Informatics
- D. Nursing certification
Correct Answer: A
Rationale: The Quality and Safety Education for Nurses (QSEN) initiative defines key competencies to ensure nurses deliver safe, high-quality care, addressing modern healthcare demands. Evidence-based practice integrates the best research with clinical expertise, guiding decisions for effective outcomes. Client-centered care prioritizes individual needs and preferences, balancing advocacy with safety. Informatics leverages technology for accurate documentation and care evaluation, enhancing efficiency. Quality improvement drives ongoing assessment and refinement of practices, while teamwork and collaboration ensure coordinated care delivery. Safety minimizes risks, a core QSEN focus. Nursing certification, though valuable, isn't a QSEN competency, as it's an individual credential, not a universal standard. These standards collectively equip nurses to improve care quality and safety across settings, reflecting a comprehensive approach to professional development and patient well-being.
These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals.
- A. Dependent
- B. Independent
- C. Interdependent
- D. Intradependent
Correct Answer: C
Rationale: Interdependent interventions rely on multiple health professionals' expertise, such as a nurse, physiotherapist, and doctor co-managing a stroke patient's rehab plan. Dependent actions follow orders (e.g., giving meds), independent ones are nurse-initiated (e.g., repositioning), and 'intradependent' isn't a term. For instance, adjusting a patient's diet with a nutritionist reflects shared knowledge, ensuring holistic care. This collaboration, common in complex cases, leverages diverse skills, enhancing outcomes like mobility or nutrition, a hallmark of modern interdisciplinary healthcare teams.
Considered as Safest and most non invasive method of temperature taking
- A. Oral
- B. Rectal
- C. Tympanic
- D. Axillary
Correct Answer: D
Rationale: Axillary temp is safest, least invasive no mucosal entry e.g., armpit avoids rectal (perforation), oral (biting), or tympanic (ear) risks. Ideal for infants, nurses use it e.g., frail patients for safety, per non-invasive guidelines.
Which of the following statement is TRUE about assault?
- A. Touching the client without consent
- B. An intentional threat
- C. Causes physical harm
- D. All of the above
Correct Answer: B
Rationale: Assault is an intentional threat (B), per law e.g., menacing gesture, no contact needed. Touching (A) is battery, harm (C) not required, all (D) oversteps. B truly defines assault's intent, making it correct.