Nokea
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.
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A nurse uses an institution's procedure manual to confirm how to insert a nasogastric tube. The level of critical thinking the nurse is using is:
- A. Basic critical thinking
- B. Commitment
- C. Complex critical thinking
- D. Scientific method
Correct Answer: A
Rationale: Basic critical thinking involves following established guidelines or procedures, like using a manual for nasogastric tube insertion, typical for novices relying on concrete rules. The nurse here seeks confirmation, indicating dependence on external standards rather than independent judgment. Commitment reflects decisive action based on internalized reasoning, not manual reliance. Complex critical thinking analyzes and adapts procedures (e.g., modifying technique for patient anatomy), requiring experience beyond rote steps. The scientific method tests hypotheses, not applicable to routine protocol checks. Basic critical thinking suits this scenario, as the nurse applies learned steps without deviation, a foundational level ensuring safe practice while building toward higher-order skills in dynamic clinical settings.
The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
- A. Instructing the patient about this diagnostic test
- B. Writing the order for this test
- C. Giving the patient breakfast
- D. All of the above
Correct Answer: C
Rationale: The nurse ensures the patient eats, while the physician handles test orders and instructions.
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
- A. Rectus femoris muscle
- B. Vastus lateralis muscle
- C. Deltoid muscle
- D. Dorsogluteal muscle
Correct Answer: B
Rationale: The vastus lateralis muscle is the preferred site for vitamin K injection in newborns, offering a large, safe muscle mass away from nerves and vessels, standard for intramuscular prophylaxis against hemorrhagic disease. Rectus femoris is smaller, deltoid underdeveloped, and dorsogluteal risky near sciatic nerve. Nurses use this site for efficacy and safety, teaching parents its purpose in clotting support.
What is nurse's primary critical observation when performing an assessment for determining an Apgar score?
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of Moro reflex
Correct Answer: A
Rationale: Apgar score assesses newborn vitality at 1 and 5 minutes post-birth across five criteria: heart rate, respiration, muscle tone, reflex, color. Heart rate (choice A) is primary; absent (<60 bpm = 0, <100 = 1, >100 = 2) dictates immediate resuscitation, making it the most critical. Respiratory rate (choice B) follows, but weak/absent breathing often ties to heart rate. Meconium (choice C) isn't scored directly, though it flags distress. Moro reflex (choice D) tests tone/reflex, secondary to vitals. A is correct, as heart rate drives initial intervention. Nurses prioritize it, ensuring rapid response to stabilize the infant.
The nurse is caring for a client with a diagnosis of cirrhosis who has developed esophageal varices. Which of the following foods should be removed from the client's diet?
- A. Custard
- B. Mashed potatoes
- C. Spinach
- D. Raisins
Correct Answer: C
Rationale: Spinach should be removed from the diet of a client with cirrhosis and esophageal varices, as its rough texture and high vitamin K content could irritate fragile varices or alter clotting, risking rupture and hemorrhage a critical concern in advanced liver disease. Custard, mashed potatoes, and raisins are softer and safer, lacking this risk. Nurses adjust diets to minimize esophageal trauma, teaching clients to avoid coarse foods, protecting against bleeding episodes that could require urgent interventions like banding or transfusion.