Nokea
These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals.
- A. Dependent
- B. Independent
- C. Interdependent
- D. Intradependent
Correct Answer: C
Rationale: Interdependent interventions rely on multiple health professionals' expertise, such as a nurse, physiotherapist, and doctor co-managing a stroke patient's rehab plan. Dependent actions follow orders (e.g., giving meds), independent ones are nurse-initiated (e.g., repositioning), and 'intradependent' isn't a term. For instance, adjusting a patient's diet with a nutritionist reflects shared knowledge, ensuring holistic care. This collaboration, common in complex cases, leverages diverse skills, enhancing outcomes like mobility or nutrition, a hallmark of modern interdisciplinary healthcare teams.
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The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.
- A. Administering the epidural injection
- B. Ensuring adequate hydration
- C. Encouraging the client to void
- D. Monitoring the condition of the fetus
Correct Answer: D
Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.
One tablet of chlorine is efficient to chlorinate how many litres of water?
- A. 10 Litres
- B. 20 Litres
- C. 30 Litres
- D. 40 Litres
Correct Answer: B
Rationale: Chlorine tablets disinfect water by releasing hypochlorous acid to kill pathogens. Standard tablets (e.g., 1 mg chlorine) are designed to treat specific volumes based on concentration needs (typically 0.5-2 mg/L). Choice A (10 L) underestimates common tablet capacity, while C (30 L) and D (40 L) exceed typical single-tablet efficacy without specifying tablet strength. B (20 L) aligns with widely used chlorine tablets (e.g., NaDCC) for household water purification, achieving safe levels per WHO guidelines. Nurses educating communities on water safety must clarify dosage, ensuring effective pathogen control without overdose, making 20 L the correct, practical answer.
A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending:
- A. Pulmonary egophony
- B. Amniotic fluid embolism
- C. Anaphylaxis
- D. Bronchospasm
Correct Answer: C
Rationale: Sudden breathing difficulty, weakness, and nausea during antibiotic administration suggest a severe allergic reaction, known as anaphylaxis. This life-threatening condition involves systemic histamine release, causing airway constriction, hypotension, and gastrointestinal distress. Pulmonary egophony relates to lung sound changes, not systemic symptoms. Amniotic fluid embolism presents with cardiovascular collapse and bleeding, not primarily nausea. Bronchospasm is airway narrowing but lacks the broader symptoms here. Immediate recognition of anaphylaxis prompts epinephrine administration and airway support, critical for maternal and fetal survival in labor.
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.
Which of the following statement is NOT true about delegation in nursing?
- A. Assigning tasks
- B. Retains accountability
- C. Only to doctors
- D. Follows scope
Correct Answer: C
Rationale: Delegation assigns tasks (A), retains accountability (B), follows scope (D) 'only to doctors' (C) isn't true, includes aides, per standards. C's restriction misstates delegation's range, like to Mr. Gary's team, making it untrue.