Nokea
The nurse is caring for a client receiving oxygen therapy via a nasal cannula. Which action by the nurse is appropriate when providing oral care to the client?
- A. Removing the nasal cannula during oral care
- B. Increasing the oxygen flow rate during oral care
- C. Applying petroleum jelly to the client's lips before oral care
- D. Instructing the client to breathe through the mouth during oral care
Correct Answer: A
Rationale: Removing the nasal cannula during oral care (A) allows thorough hygiene without interference, briefly tolerable given short duration. Increasing flow (B) is unnecessary. Petroleum jelly (C) isn't for oral care. Mouth breathing (D) isn't needed if removed. Removal, per nursing practice, ensures effective care.
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Mr. Gary moved from hospital to rehab with a care plan. This is an example of?
- A. Care transition
- B. Chronic disease management
- C. Health promotion
- D. Nursing informatics
Correct Answer: A
Rationale: Moving from hospital to rehab with a plan is care transition (A) setting shift, per definition. Management (B) ongoing, promotion (C) preventive, informatics (D) tech not transition-specific. A fits care handoff, making it correct.
One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client?
- A. Incident report completed.'
- B. the reason the client was unattended
- C. the vital signs and assessment of the client
- D. location of the incident report
Correct Answer: C
Rationale: After a fall, recording vital signs and assessment in nursing notes is most needed, providing a clinical picture post-incident like stable pulse and no fractures for care and legal purposes. Noting the report's completion or location is administrative, and explaining absence justifies but doesn't document health status. This ensures comprehensive client-focused documentation.
A theory is a set of concepts, definitions, relationships and assumptions that:
- A. Explain a phenomenon
- B. Formulate legislation
- C. Measure nursing functions
- D. Reflect the domain of nursing practice
Correct Answer: A
Rationale: A theory e.g., Henderson's uses concepts (e.g., breathing), definitions (clarifying terms), relationships (how needs interact), and assumptions (e.g., patients seek independence) to explain phenomena like recovery. This informs nursing actions e.g., why positioning aids breathing. Formulating legislation is policy, not theory's role indirectly influenced. Measuring functions suits research, not theory's explanatory purpose. Reflecting the domain describes scope, not function explanation is active. Theories explain health-related events, providing nurses frameworks to understand and address client needs, making this the precise definition.
A patient develops red eyes 2 days after an episode of malaria probable cause is:
- A. Conjunctivitis
- B. Anterior uveitis
- C. Viral keratitis
- D. Endophthalmitis
Correct Answer: B
Rationale: Red eyes post-malaria suggest an ocular complication. Conjunctivitis (choice A) causes redness but isn't typically linked to malaria unless secondary infection occurs. Anterior uveitis (choice B), inflammation of the iris and ciliary body, is a rare but documented malaria sequel, possibly from immune response or parasite-related damage, presenting with redness, pain, and photophobia. Viral keratitis (choice C) affects the cornea and is unrelated to malaria. Endophthalmitis (choice D), a severe intraocular infection, is unlikely without trauma or surgery. B is correct, as anterior uveitis aligns with malaria's systemic inflammatory effects. Nurses should assess eye symptoms, refer to ophthalmology, and manage pain, preventing vision loss in such cases.
Which of the following is TRUE about the blood pressure determinants?
- A. Hypervolemia lowers BP
- B. Hypervolemia increases GFR
- C. HCT of 70% might decrease or increase BP
- D. Epinephrine decreases BP
Correct Answer: C
Rationale: HCT 70% e.g., polycythemia can raise BP (viscosity) or lower (poor flow), unlike hypervolemia (raises BP, GFR), or epinephrine (raises). Nurses assess this e.g., anemia for impacts, per dynamics.