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What is the fundamental difference between nursing diagnoses and collaborative problems?
- A. Collaborative problems are managed by nurses using physician-prescribed interventions.
- B. Collaborative problems can be addressed by independent nursing interventions.
- C. Physician-prescribed interventions are incorporated into nursing diagnoses.
- D. Nursing diagnoses include physiologic complications that nurses monitor to detect status changes.
Correct Answer: B
Rationale: The correct answer is B, as collaborative problems necessitate the collective expertise and skills of numerous healthcare professionals, including nurses. These problems can be dealt with through independent nursing interventions in cooperation with other team members. Option A is incorrect because collaborative problems aren't strictly managed with physician-prescribed interventions. Option C is incorrect because nursing diagnoses aim at identifying and treating actual or potential health issues, rather than merely integrating physician-prescribed interventions. Option D is incorrect because nursing diagnoses aim at identifying patient issues, not solely physiologic complications, and guide the necessary nursing care, not just monitor for changes.
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What is the name of the record that shows all medications and treatments provided on a repeated basis?
- A. Nursing Health History and Assessment Worksheet
- B. Discharge Summary
- C. Nursing Kardex
- D. Medicine and Treatment Record
Correct Answer: D
Rationale: The 'Medicine and Treatment Record' is the document that maintains a comprehensive log of all medications and treatments provided on a routine basis. It does not refer to the 'Discharge Summary', which is a clinical report prepared by healthcare professionals at the end of a hospital stay or series of treatments. The 'Nursing Health History and Assessment Worksheet' is used to gather comprehensive data about the patient's health history and current health status, but it does not record ongoing treatment details. The 'Nursing Kardex' is a patient care information system used to quickly communicate patient needs, but it does not consistently record all medications and treatments provided.
During operation, who manages the lighting, noise, temperature and other factors in the operating room suite?
- A. Nurse Supervisor
- B. Surgeon
- C. Circulating Nurse
- D. Scrub Nurse
Correct Answer: C
Rationale: In an operating room, the circulating nurse is responsible for managing environmental factors such as lighting, noise, and temperature. This role includes ensuring the comfort and safety of the patient, as well as the efficiency of the team. While the Nurse Supervisor, Surgeon, and Scrub Nurse also have crucial roles during an operation, they do not directly manage the environmental conditions of the operating room. The rationale provided does not directly address the question asked, and appears to relate more to the broader role of nursing in patient care.
Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?
- A. Self-esteem disturbance
- B. Impaired urinary elimination
- C. Impaired skin integrity
- D. Risk for infection
Correct Answer: D
Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.
Which food items should be consumed with nonheme iron to increase its absorption, according to a nurse's education plan for clients?
- A. Kiwi
- B. Strawberries
- C. Coffee
- D. Kiwi and Strawberries
Correct Answer: D
Rationale: The correct answer is D: Kiwi and Strawberries. Both of these fruits are high in vitamin C, a nutrient known to enhance the absorption of nonheme iron. Vitamin C facilitates the conversion of nonheme iron into a form that is more readily absorbed by the body, thereby enhancing iron intake. In contrast, coffee (Choice C) contains certain compounds that can actually inhibit the absorption of iron, making it a less desirable choice when the goal is to increase iron absorption. Consequently, Choices A (Kiwi), B (Strawberries), and C (Coffee) were specifically picked to highlight the varying effects of different food items on nonheme iron absorption.
When taking a blood pressure reading, where should the cuff be positioned?
- A. The cuff should be deflated fully before immediately starting a second reading for the same patient
- B. The cuff should be deflated quickly after being inflated to 180 mmHg
- C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
- D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery
Correct Answer: D
Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.