Nokea
The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
- A. Changing the position of the mask every 2 hours
- B. Applying a protective barrier cream to the client's face
- C. Padding the pressure points on the client's face with soft material
- D. Encouraging the client to remove the mask intermittently for facial skin care
Correct Answer: C
Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.
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The nurse raised her fist to Mr. Gary who refused his medication. This is an example of?
- A. Malpractice
- B. Negligence
- C. Assault
- D. Battery
Correct Answer: C
Rationale: Raising a fist to Mr. Gary is assault (C) intentional threat, per law. Malpractice (A) and negligence (B) are care failures, battery (D) requires touch. C fits the threatening act, making it correct.
The client has an allergy with penicillin. What is the best way to communicate this information?
- A. Place an allergy alert in the Kardex
- B. Notify the attending physician
- C. Write it on the patient's chart
- D. Take note when giving medications
Correct Answer: A
Rationale: Placing an allergy alert in the Kardex (A) is best; it's immediately accessible to all staff, per safety protocols. Notifying the physician (B) or charting (C) delays visibility, noting mentally (D) risks errors. A ensures quick action, making it correct.
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 an inappropriate order like morphine for pancreatitis, which worsens sphincter of Oddi spasm reflects the client advocate role. Nurses protect patient rights and safety by challenging harmful directives, ensuring optimal care (e.g., suggesting alternatives like meperidine). This differs from change agent (lifestyle shifts), case manager (coordination), or collaborator (teamwork), emphasizing advocacy's focus on patient well-being, a core ethical duty in nursing.
Which of the following statement is TRUE about patient safety?
- A. Only about medication
- B. Prevents harm in care
- C. Not a nursing concern
- D. All of the above
Correct Answer: B
Rationale: Patient safety prevents harm in care (B), per standards e.g., fall prevention. Not just meds (A), is nursing concern (C), not all (D) broad focus. B truly defines safety's aim, making it correct.
The nurse reviewed Mr. Gary's care to reduce errors. This is an example of?
- A. Quality improvement
- B. Patient-centered care
- C. Nursing informatics
- D. Health promotion
Correct Answer: A
Rationale: Reviewing care to reduce errors is quality improvement (A) enhancing processes, per definition. Patient-centered (B) tailors, informatics (C) tech, promotion (D) well-being not error-focused. A fits QI's aim, making it correct.