Nokea
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.
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Which of the following statement best describe battery?
- A. Failure to meet the standard of care
- B. An intentional threat
- C. Touching the client without consent
- D. Causes emotional harm
Correct Answer: C
Rationale: Battery is touching without consent (C), per law e.g., unpermitted procedure. Standards (A) is malpractice, threat (B) assault, emotional harm (D) not key. C best defines battery's physical breach, making it correct.
Which of the following statement is NOT true about Hospice care?
- A. Offered to terminally ill client
- B. The client's family is included in the care
- C. Focuses on relieving symptoms
- D. Requires client to sign a DNR
Correct Answer: D
Rationale: Hospice cares for terminally ill (A), includes family (B), and relieves symptoms (C), per hospice philosophy. Requiring a DNR (D) isn't true preferred, not mandatory; care focuses on comfort, not resuscitation status. D's absolute requirement misaligns with flexibility, making it the untrue statement.
Which activity is an example of health promotion by the nurse
- A. Administering immunizations
- B. Giving a bedbath
- C. Preventing complications after an accident
- D. Performing diagnostic procedures
Correct Answer: A
Rationale: Health promotion enhances well-being and prevents disease proactively administering immunizations (e.g., measles vaccine) exemplifies this, boosting immunity before illness strikes. Giving a bedbath is hygiene, not promotion supportive, not preventive. Preventing complications post-accident is tertiary prevention, managing existing issues, not promoting health preemptively. Diagnostic procedures (e.g., blood tests) detect, not promote assessment, not prevention. Immunizations align with health promotion's focus on empowering clients against disease, a core nursing role in public health, making this the standout example.
Which of the following is considered normal adult bladder capacity?
- A. 100-200 ml
- B. 400-500 ml
- C. 50-100 ml
- D. 800-1000 ml
Correct Answer: B
Rationale: Adult bladder capacity is 400-500 ml e.g., typical urge at 300-400. Less (50-200) or more (800-1000) don't fit. Nurses note e.g., catheter output for function, per physiology.
Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?
- A. Allowing the patient to cry
- B. Encouraging unrestricted visiting
- C. Explaining the patient what is being done
- D. Being around though not speaking
Correct Answer: D
Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.