Nokea
The nurse is suctioning a client through a tracheal tube. During the procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?
- A. Notify the registered nurse immediately.
- B. Stop the procedure and oxygenate the client.
- C. Continue to suction the client at a quicker pace.
- D. Ensure that the suction is limited to 15 seconds.
Correct Answer: B
Rationale: A 10-beat heart rate drop during suctioning suggests vagal stimulation or hypoxia; stopping the procedure and oxygenating (B) is the next action to reverse this. Notifying the RN (A) or limiting time (D) follows. Continuing (C) risks worsening. B is correct. Rationale: Suctioning can trigger bradycardia via vagal nerve activation or oxygen depletion; halting and oxygenating restores stability, a critical step per airway management guidelines, preventing further cardiac compromise.
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The nurse forgot to give Mr. Gary his medication, causing harm. This is an example of?
- A. Negligence
- B. Malpractice
- C. Assault
- D. Battery
Correct Answer: A
Rationale: Forgetting meds causing harm is negligence (A) care standard failure, per law. Malpractice (B) professional-specific, assault (C) threat, battery (D) touch not general lapse. A fits the nurse's unintentional error impacting Mr. Gary, making it correct.
Nephrotic syndrome is characterised by:
- A. Proteinuria
- B. Edema
- C. Hyperlipidemia
- D. All of the above
Correct Answer: D
Rationale: Nephrotic syndrome disrupts kidney filtration. Proteinuria (choice A) exceeds 3.5 g/day, causing hypoalbuminemia. Edema (choice B) results from low oncotic pressure, fluid shifting to tissues. Hyperlipidemia (choice C) occurs as the liver compensates for protein loss. All (choice D) are hallmarks, correct per definition. Nurses monitor urine protein, manage swelling, and educate on diet, addressing this triad.
What is the purpose of utilizing proper positioning techniques for patients?
- A. To maintain patient comfort
- B. To promote social interaction
- C. To facilitate ambulation
- D. To improve coordination
Correct Answer: A
Rationale: Proper positioning techniques aim to maintain patient comfort by reducing pressure points, aligning the body, and preventing pain or discomfort during rest or treatment. This focus enhances patient well-being, crucial for recovery and satisfaction in care settings. Encouraging social engagement, aiding walking, or enhancing coordination, while valuable, aren't the core objectives of positioning those require distinct interventions like group activities or physical therapy. Comfort underpins healing, as unrelieved pressure or misalignment can lead to complications like ulcers or muscle strain. Nurses prioritize this to support physiological stability, ensuring patients feel at ease, which indirectly supports broader therapeutic goals without being the primary intent.
A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following statements should be included by the healthcare provider?
- A. Increase your intake of sodium-rich foods.
- B. Decrease your intake of sodium-rich foods.
- C. Avoid foods that contain lactose.
- D. Increase your intake of dairy products.
Correct Answer: B
Rationale: The correct answer is B: 'Decrease your intake of sodium-rich foods.' When managing hypertension, reducing the intake of sodium-rich foods is essential. Excessive sodium can contribute to increased blood pressure, which is why limiting its consumption is crucial to prevent complications. Choices A, C, and D are incorrect. Increasing sodium intake would exacerbate hypertension, avoiding lactose is unrelated to managing hypertension, and increasing dairy product intake does not specifically address the issue of sodium intake in hypertension management.
Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well the elements of effecting charting?
- A. She signs her charting as follows: J.R
- B. She writes in the chart using a no. 2 pencils.
- C. She noted: appetite is good this afternoon.
- D. She signs on the medication sheet after administering the medication.
Correct Answer: D
Rationale: Effective charting requires accuracy, clarity, and accountability, adhering to legal and professional standards. Signing the medication sheet after administering medication, as Nurse Jane does, exemplifies this by confirming the intervention occurred, ensuring patient safety, and providing a verifiable record. This practice aligns with the 'Five Rights' of medication administration and reduces error risks, such as double-dosing. Conversely, signing as 'J.R.' lacks full identification (name and title), compromising accountability. Using a pencil risks erasure or alteration, undermining record integrity, as permanent ink is standard. Noting 'appetite is good' is subjective and lacks detail (e.g., meal percentage consumed), reducing its clinical value. Nurse Jane's action of signing post-medication administration reflects a strong grasp of charting's role in care continuity and safety, making it the best demonstration of effective documentation principles.