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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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One of the primary reasons for conducting nursing research is to:
- A. Decrease costs associated with client care
- B. Generate knowledge to guide practice
- C. Allow nurses to delegate more tasks
- D. Assist physicians in their research
Correct Answer: B
Rationale: Nursing research's primary aim is to generate knowledge to guide practice, building a scientific foundation that informs and improves care delivery. This involves studying interventions like pain management techniques or outcomes, like recovery rates, to create evidence-based guidelines that enhance safety and effectiveness. Decreasing costs, while a potential byproduct, isn't the core focus; research prioritizes quality over economics. Delegating tasks relates to workflow, not research goals, and assisting physicians, though collaborative, isn't nursing's aim its focus is autonomous advancement. This knowledge generation refines assessment, planning, and intervention, ensuring nurses address client needs with precision. For example, research on pressure ulcer prevention shapes protocols, directly impacting practice. This purpose elevates nursing as a science-driven profession, distinct from mere support roles, fostering innovation and accountability in healthcare.
The nurse asked an aide to check Mr. Gary's vitals. This is an example of?
- A. Delegation
- B. Responsibility
- C. Malpractice
- D. Health policy
Correct Answer: A
Rationale: Asking an aide for vitals is delegation (A) task assignment, per definition. Responsibility (B) duty, malpractice (C) breach, policy (D) rules not delegation-specific. A fits the nurse's supervised task for Mr. Gary, making it correct.
The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of $20 \mathrm{mmHg}$. Which action made by the client is responsible for this condition?
- A. Drinking lots of water
- B. Eating high-fiber foods
- C. Bending over at the waist
- D. Bending knees when lowering body
Correct Answer: C
Rationale: ICP of 20 mmHg (elevated) post-hypophysectomy is likely from bending over (C), increasing venous pressure to the brain. Drinking (A) or eating fiber (B) don't directly raise ICP. Knee bending (D) is safe. C is correct. Rationale: Bending elevates intracranial venous return, spiking ICP in a fragile post-surgical state, per neurocare principles, unlike neutral activities.
Which of the following condition has an increased risk of for developing hyperkalemia?
- A. Crohn's disease
- B. Cushing's disease
- C. Chronic heart failure
- D. End-stage renal disease
Correct Answer: D
Rationale: End-stage renal disease impairs potassium excretion, causing hyperkalemia as kidneys fail to filter excess. Crohn's affects absorption, Cushing's alters cortisol, and heart failure impacts circulation not potassium directly. Nurses monitor levels in renal patients, adjusting diet or dialysis to prevent arrhythmias or muscle issues from high potassium, a common complication.
The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.
- A. Administering the epidural injection
- B. Ensuring adequate hydration
- C. Encouraging the client to void
- D. Monitoring the condition of the fetus
Correct Answer: D
Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.