Nokea
The nurse reported Mr. Gary's fall to improve safety. This is an example of?
- A. Incident reporting
- B. Documentation
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Reporting a fall is incident reporting (A) adverse event log, per definition. Documentation (B) records, promotion (C) well-being, transition (D) moves not report-specific. A fits the nurse's action for Mr. Gary's safety, making it correct.
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He was called the father of sanitation.
- A. Abraham
- B. Hippocrates
- C. Moses
- D. Willam Halstead
Correct Answer: C
Rationale: Moses, in ancient Hebrew texts, introduced sanitation laws e.g., waste disposal, quarantine earning the ‘father of sanitation' title. Abraham (patriarch), Hippocrates (medicine), and Halstead (surgery) differ. His rules, like Leviticus' hygiene codes, predate modern sanitation, influencing public health and nursing's infection control roots.
When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
- A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
- B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
- C. The chart is a legal document and may be all a nurse has to support care that was given if called to court.
- D. Clients need to be assessed and the care documented at least once every hour during the shift.
Correct Answer: C
Rationale: Documentation is a cornerstone of nursing practice, and recognizing the chart as a legal document is paramount. It serves as the primary evidence of care provided, protecting the nurse in legal disputes by detailing actions, observations, and client responses. If called to court, this record may be the only defense against claims of negligence or improper care, making accuracy and completeness essential. Brevity might compromise detail, undermining its legal value, while specific formats like SOAP enhance clarity but aren't the core issue. Hourly documentation isn't universally required unless specified by policy; the focus is on capturing significant events. This understanding ensures nurses document with precision, safeguarding both client care and professional accountability in a legal context.
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?
- A. Administer insulin
- B. Administer oxygen
- C. Feed the infant glucose water (10%)
- D. Place infant in a warmer
Correct Answer: C
Rationale: Jitteriness and lethargy suggest hypoglycemia, common in infants of diabetic mothers; glucose water corrects this.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
- A. That the infant will need daily calcium supplements
- B. To lift the infant by the buttocks when diapering
- C. That the condition is a temporary one
- D. That only the bones are affected by the disease
Correct Answer: B
Rationale: Lifting by the buttocks prevents fractures in osteogenesis imperfecta, a brittle bone disorder calcium doesn't strengthen defective collagen, it's lifelong, and other systems (e.g., hearing) may be affected. Nurses teach gentle handling, ensuring safety in this genetic condition.
What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Monitoring I&O ensures fluid balance with hyperosmotic enteral feeding.