Nokea
The nurse touched Mr. Gary without consent during care. This is an example of?
- A. Battery
- B. Assault
- C. Justice
- D. Nonmaleficence
Correct Answer: A
Rationale: Touching without consent is battery (A) unconsented contact, per law. Assault (B) threat, justice (C) fairness, nonmaleficence (D) harm avoidance not contact-specific. A fits the nurse's breach of Mr. Gary's autonomy, making it correct.
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A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?
- A. Prepare for reintubation.
- B. Call the health care provider.
- C. Call the rapid response team.
- D. Check the client for spontaneous breathing.
Correct Answer: D
Rationale: If a tracheostomy tube is dislodged, checking for spontaneous breathing (D) is the priority to assess airway patency and oxygenation need. Preparing for reintubation (A) or calling teams (B, C) follows. D is correct. Rationale: Assessing breathing determines if immediate reinsertion or oxygenation is urgent, guiding next steps per respiratory emergency standards, ensuring patient stability first.
Which of the following statement is NOT true about legal documentation?
- A. Supports care quality
- B. Legal evidence
- C. Can be altered anytime
- D. Must be accurate
Correct Answer: C
Rationale: Legal documentation supports quality (A), is evidence (B), must be accurate (D) 'can be altered anytime' (C) isn't true, strict rules apply, per law. C's flexibility contradicts standards, like Mr. Gary's records, making it untrue.
Palpating the midclavicular line is the correct technique for assessing
- A. Baseline vital signs
- B. Systolic blood pressure
- C. Respiratory rate
- D. Apical pulse
Correct Answer: D
Rationale: The midclavicular line locates the apical pulse at the heart's apex.
An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?
- A. Perform physical assessment
- B. Have the client rate his pain on the smiley pain rating scale
- C. Active listening on what the patient says
- D. Observe the client's behavior
Correct Answer: B
Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.
Which technique would be best in caring for a client following receiving a diagnosis of a stage IV tumor in the brain?
- A. Offering the client pamphlets on support groups for brain cancer
- B. Asking the client if there is anything he or his family needs
- C. Reminding the client that advances in technology are occurring everyday
- D. Providing accurate information about the disease and treatment options
Correct Answer: D
Rationale: Accurate information empowers the client and family to make informed decisions.