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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A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
- A. Writing down all assignments
- B. Making changes after evaluating the situation and having discussions with the staff
- C. Telling the staff nurses that she is making changes to benefit their performance
- D. Evaluating the clinical performance of each staff nurse in a private conference
Correct Answer: B
Rationale: Evaluating and discussing changes eases transition and builds trust.
The nurse is caring for a client with a fractured tibia placed in an external fixator. Which of the following should be included in the plan of care?
- A. Keeping the leg flat at all times
- B. Checking the pin sites for signs of infection
- C. Massaging the leg to promote circulation
- D. Ambulating the client within 12 hours of application
Correct Answer: B
Rationale: Checking pin sites for infection (redness, drainage) is critical in external fixator care for a fractured tibia, preventing osteomyelitis flat legs, massage, or early ambulation risk stability or healing. Nurses monitor this, ensuring site care and antibiotics if needed, supporting bone recovery.
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 patients is at greatest risk for developing pressure ulcers?
- A. An alert, chronic arthritic patient treated with steroids and aspirin
- B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home
- C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula
- D. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed
Correct Answer: B
Rationale: Age, immobility, incontinence, and malnutrition heighten pressure ulcer risk.
The nurse reported Mr. Gary's fall to improve safety. This is an example of?
- A. Incident reporting
- B. Documentation
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Reporting a fall is incident reporting (A) adverse event log, per definition. Documentation (B) records, promotion (C) well-being, transition (D) moves not report-specific. A fits the nurse's action for Mr. Gary's safety, making it correct.