Nokea
The nurse recorded Mr. Gary's vitals in his chart. This is an example of?
- A. Documentation
- B. Standard precautions
- C. Health policy
- D. Patient education
Correct Answer: A
Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.
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As a nurse manager, which of the following best describes this function?
- A. Initiate modification on client's lifestyle
- B. Protect client's right
- C. Coordinates the activities of other members of the health team in managing patient care
- D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution
Correct Answer: D
Rationale: A nurse manager's role encompasses planning (vision formulation), organizing (team coordination), directing (training), and controlling (audits), per management theories like Venzon's. This holistic function e.g., setting care standards, training staff, evaluating outcomes ensures quality across a unit, unlike narrower roles like lifestyle change (change agent), rights protection (advocate), or team coordination (case manager). It's a strategic position driving institutional excellence, pivotal in healthcare leadership.
An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
- A. Stiffness of the right ankle joint
- B. Soreness of the gums
- C. Short-term memory loss
- D. Decreased appetite
Correct Answer: A
Rationale: Joint stiffness signals early contractures or atrophy from immobility.
When caring for a client receiving oxygen therapy, the nurse identifies condensation in the oxygen tubing. What action should the nurse take?
- A. Increase the oxygen flow rate to prevent condensation
- B. Disconnect the tubing and drain the condensation
- C. Replace the oxygen tubing with a new one immediately
- D. Place a heat-moisture exchanger (HME) on the oxygen tubing
Correct Answer: B
Rationale: Disconnecting and draining condensation (B) resolves impedance in oxygen flow from water buildup, maintaining effective delivery. Increasing flow (A) doesn't address it. Replacing tubing (C) is unnecessary if drained. HME (D) is for humidification, not condensation. Draining, per respiratory care, ensures uninterrupted therapy.
The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?
- A. Call a code.
- B. Administer a bronchodilator.
- C. Contact the health care provider.
- D. Disconnect the suction source from the catheter.
Correct Answer: D
Rationale: A stuck catheter with coughing and wheezing suggests obstruction or bronchospasm; disconnecting the suction source (D) is the priority to relieve pressure and attempt removal. Calling a code (A) or provider (C) delays action. Bronchodilators (B) treat wheezing but not the immediate issue. D is correct. Rationale: Disconnecting stops suction trauma, allowing catheter withdrawal and airway reassessment, a critical first step per emergency airway protocols.
Which of the following statement best describe quality improvement?
- A. A one-time fix
- B. Ongoing effort to enhance care
- C. A punishment for errors
- D. A financial strategy
Correct Answer: B
Rationale: Quality improvement is an ongoing effort to enhance care (B), per QI models e.g., PDSA cycles. Not one-time (A), not punishment (C), not just finance (D) continuous. B best defines QI's iterative nature, making it correct.