Nokea
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
- A. Hydrocolloid
- B. Transparent
- C. Gauze
- D. Alginate
Correct Answer: A
Rationale: The correct answer is A: Hydrocolloid dressing. For a stage 2 pressure injury, a hydrocolloid dressing is ideal as it maintains a moist environment to promote healing, absorbs excess exudate, and provides a barrier against bacteria. Transparent dressings (B) are more suitable for superficial wounds. Gauze dressings (C) may adhere to the wound bed and cause trauma upon removal. Alginate dressings (D) are better for wounds with heavy exudate, not typically seen in stage 2 pressure injuries.
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A client complains every morning that the night shift nursing staff does not answer his call light promptly to assist his elimination needs. His concerns are not shared with the Nurse Manager, and he falls while trying to walk to the bathroom. This fall could be attributed to which of the following?
- A. Breakdown in communication
- B. Lack of staff
- C. Lack of concern
- D. Breakdown in management
Correct Answer: A
Rationale: The correct answer is A: Breakdown in communication. The client's complaint about the night shift nursing staff not responding promptly to his call light indicates a lack of effective communication between the client and the staff. This breakdown in communication leads to the client attempting to walk to the bathroom alone, resulting in a fall. Lack of staff (B) or lack of concern (C) are not directly related to the client's fall, as the core issue lies in communication. Breakdown in management (D) could contribute to communication issues, but the immediate cause of the fall is the lack of communication between the client and the nursing staff.
A nurse recognizes which of the following as a primary goal of nursing?
- A. Assist patients to achieve a peaceful death.
- B. Improve personal knowledge and skills to enhance patient outcomes.
- C. Advocate for quality of life over the quantity of life.
- D. Work to control costs to enhance patients' quality of life.
Correct Answer: A
Rationale: The correct answer is A because the primary goal of nursing is to provide holistic care, which includes helping patients achieve a peaceful death. This involves promoting comfort, dignity, and emotional support for patients and their families at the end of life. Choice B focuses on personal development, not the primary goal of nursing. Choice C emphasizes quality of life, which is important but not the primary goal. Choice D prioritizes cost control, which is not the central focus of nursing care. Overall, assisting patients to achieve a peaceful death reflects the essence of nursing care and the importance of compassion and support in end-of-life situations.
A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent
feedings through an open system. Which of the following actions should the nurse take first?
- A. Make sure the enteral formula is at room temperature.
- B. Wipe the top of the formula can with alcohol.
- C. Rinse the feeding bag with water between feedings.
- D. Tell the client to keep the head of the bed elevated at least 30°
Correct Answer: B
Rationale: The correct answer is B: Wipe the top of the formula can with alcohol. This is the first action the nurse should take because it ensures the cleanliness and sterility of the formula before administering it to the client through the NG tube, reducing the risk of contamination and infection.
A: Making sure the enteral formula is at room temperature is important but not the first action to take.
C: Rinsing the feeding bag with water between feedings is not necessary for every feeding and does not address the immediate need to ensure the cleanliness of the formula.
D: Instructing the client to keep the head of the bed elevated is important for preventing aspiration but is not the first action to take in this scenario.
What is the best description of cultural competence in nursing?
- A. Ignoring cultural differences
- B. Adapting care to cultural needs
- C. Learning about different cultures
- D. Teaching cultural awareness
Correct Answer: B
Rationale: The correct answer is B because cultural competence in nursing involves adapting care to meet the cultural needs and preferences of each individual patient. This includes understanding and respecting their beliefs, values, and practices to provide effective and respectful care. Ignoring cultural differences (A) goes against the core principle of cultural competence. Simply learning about different cultures (C) is not enough; it is essential to apply that knowledge in practice. Teaching cultural awareness (D) is important but does not fully capture the holistic approach of adapting care to meet cultural needs.
Which of the following laws govern nursing practice?
- A. Statutory laws
- B. Common law
- C. Administrative laws
- D. Constitutional laws
Correct Answer: A
Rationale: The correct answer is A: Statutory laws. Nursing practice is primarily governed by statutory laws, which are laws enacted by legislative bodies such as state nursing practice acts. These laws outline the scope of practice, licensure requirements, and standards of care for nurses. Common law, administrative laws, and constitutional laws do not specifically regulate nursing practice. Common law refers to legal precedents established by court decisions, administrative laws pertain to regulations set by administrative agencies, and constitutional laws deal with the fundamental principles outlined in the constitution. Therefore, A is the correct choice as it directly relates to the specific legal framework that governs nursing practice.