Nokea
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.
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Which of the following statement best describe health policy?
- A. A hospital rule
- B. Rules affecting health care
- C. A patient's choice
- D. A medical procedure
Correct Answer: B
Rationale: Health policy is rules affecting health care (B), per definition e.g., laws on access. Not hospital (A), patient (C), procedure (D) systemic. B best defines policy's governance, making it correct.
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
Myra told Budek 'I cannot sleep, I stay away all night' Budek told her 'You have difficulty sleeping' This is what type of therapeutic communication technique?
- A. Reflecting
- B. Restating
- C. Exploring
- D. Seeking clarification
Correct Answer: B
Rationale: Budek's 'You have difficulty sleeping' is restating (B), rephrasing Myra's 'I cannot sleep' to show listening. Reflecting (A) echoes feelings (e.g., 'You're restless?'). Exploring (C) probes (e.g., 'Why can't you?'). Clarification (D) seeks meaning (e.g., 'What keeps you awake?'). Restating validates Myra's issue, per communication theory, making B correct.
A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
- A. Call the physician
- B. Remedicate the patient
- C. Observe the emesis
- D. Explain to the patient that she can do nothing to help him
Correct Answer: C
Rationale: Observing the emesis checks for medication remnants, guiding next steps.
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.