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The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: All are critical to monitor bleeding risks and heparin efficacy.
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The goal of nursing is to put the patient in the best condition for nature to act upon him'. This was stated by
- A. Henderson
- B. Jean Watson
- C. Marta Rogers
- D. Florence Nightingale
Correct Answer: D
Rationale: This quote reflects a historical view of nursing as facilitating natural healing, attributed to Florence Nightingale, the founder of modern nursing. In her 1859 work, *Notes on Nursing*, she emphasized optimizing the patient's environment cleanliness, air, and rest for recovery. Henderson defined nursing through 14 basic needs, Watson focused on caring theory, and Rogers developed a science of unitary beings none match this phrasing. Nightingale's philosophy shaped nursing's focus on holistic care, influencing practice for centuries by prioritizing patient conditions over direct intervention.
The nurse returned to check Mr. Gary as promised. This is an example of?
- A. Fidelity
- B. Veracity
- C. Justice
- D. Beneficence
Correct Answer: A
Rationale: Returning as promised is fidelity (A) keeping commitments, per ethics. Veracity (B) is truth, justice (C) fairness, beneficence (D) good not promise-specific. A reflects the nurse's reliability, fostering trust with Mr. Gary, aligning with fidelity's ethical role in nursing, making it correct.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy at home. What should the nurse include in the client's teaching regarding oxygen safety?
- A. Ensure you have a fire extinguisher readily available
- B. Keep the oxygen tubing loose to prevent tangling
- C. Avoid using electric heating devices in your home
- D. Use an oxygen concentrator for outdoor activities
Correct Answer: C
Rationale: Avoiding electric heating devices (C) is critical in COPD oxygen therapy teaching, as oxygen accelerates combustion, posing a fire risk. Fire extinguisher (A) is supplementary. Loose tubing (B) risks disruption. Concentrator use (D) depends on need. Safety education, per home care standards, prioritizes fire prevention.
The nurse double-checked Mr. Gary's meds to avoid mistakes. This is an example of?
- A. Safety
- B. Quality improvement
- C. Patient-centered care
- D. Telemedicine
Correct Answer: A
Rationale: Double-checking meds is safety (A) preventing harm, per care standards. QI (B) enhances, patient-centered (C) tailors, telemedicine (D) remote not error-specific. A fits safety's focus, making it correct.
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.