Nokea
The nurse is educating staff on adult basic life support. It would be appropriate to include which of the following? Select all that apply.
- A. Carotid pulse check should not take more than 20 seconds.
- B. The rate of chest compressions should be 100-120 per minute.
- C. Chest compression depth should be 2 inches on the center breastbone.
- D. Chest tube insertion should be prepared after five minutes of CPR.
- E. Early defibrillation is essential in the survival of ventricular fibrillation.
Correct Answer: B, E
Rationale: Chest compression rate of 100-120/minute (B) and early defibrillation for ventricular fibrillation (E) are correct per AHA guidelines. Pulse check is ≤10 seconds (A), depth is ~2.4 inches (C), and chest tube insertion (D) is not part of BLS.
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The registered nurse (RN) and licensed practical/vocational nurse (LPN/VN) are caring for a client with an infected leg ulcer. Which task should the RN delegate to the LPN/VN?
- A. Obtain wound cultures during dressing changes
- B. Teach the client about high-protein food choices
- C. Assess the risk for further skin breakdown
- D. Initiate an outpatient wound care referral
Correct Answer: A
Rationale: Obtaining wound cultures during dressing changes (A) is a technical task within the LPN’s scope. Teaching (B), risk assessment (C), and referral initiation (D) require RN-level judgment and education skills.
The nurse has learned during nursing school to maintain honesty and openness with all clients, even when conveying potentially distressing information. This approach aligns with the ethical principle of
- A. beneficence.
- B. veracity.
- C. nonmaleficence.
- D. fidelity.
Correct Answer: B
Rationale: Honesty and openness (B) align with veracity, the ethical principle of truth-telling. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and fidelity (D) keeps promises, but veracity is most relevant here.
The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.
A client has used a condescending tone towards the nurse, subsequently angering the nurse. Which response by the nurse would be most therapeutic?
- A. That tone of voice makes me feel upset.'
- B. You make me angry when you talk like that.'
- C. Are you trying to upset me?'
- D. Why do you use that tone of voice with me?'
Correct Answer: A
Rationale: Expressing feelings using 'I' statements (A) is therapeutic, promoting open communication without blame. Blaming the client (B), assuming intent (C), or questioning their tone (D) escalates conflict and is non-therapeutic.
The nurse is reviewing leadership and management concepts with a student nurse. The student nurse demonstrates understanding if they made which of the following statements? Select all that apply.
- A. Battery is an intentional touching of another's body without the other's consent.'
- B. Assault is when the nurse makes a verbal or physical threat.'
- C. Unintentional torts include negligence and malpractice.'
- D. Defamation is presenting false credentials for employment.'
- E. Occurrence reports reduce the liability for a negligent tort.'
Correct Answer: A, B, C
Rationale: Battery (A) is non-consensual touching, assault (B) is a threat, and negligence/malpractice (C) are unintentional torts, all correct. Defamation (D) involves false statements harming reputation, not credentials, and occurrence reports (E) document but don’t reduce liability.