Nokea
When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:
- A. Protect the patient from injury
- B. Insert an airway
- C. Elevate the head of the bed
- D. Withdraw all pain medications
Correct Answer: A
Rationale: Protecting an unconscious patient from injury is the top priority.
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While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?
- A. crackles
- B. Rales
- C. adventitious sounds
- D. pleral friction rub
Correct Answer: C
Rationale: Continuous abnormal lung sounds are charted as adventitious, encompassing wheezes or rubs, unlike intermittent crackles or rales. Pleural rub is specific. Nurses document this for respiratory evaluation.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth
- B. The medication will be needed throughout the child's lifetime
- C. The medication schedule can be arranged to allow for drug holidays
- D. The medication is given one time daily every other day
Correct Answer: B
Rationale: Lifetime thyroid hormone replacement is needed for congenital hypothyroidism to prevent developmental delays growth spurts, holidays, or alternate days don't suffice. Nurses reinforce this, ensuring adherence, critical for normal growth in this endocrine disorder.
When charting in the client's record or chart, the nurse most needs to do which one of the following things?
- A. Date and sign each entry.
- B. Chart every two hours.
- C. Use ballpoint pen and not pencil.
- D. Cross out errors so others can't read them.
Correct Answer: A
Rationale: Dating and signing each chart entry is most essential, establishing a legal timeline and accountability for actions. Fixed intervals aren't mandatory, pens ensure permanence but aren't the priority, and crossing out errors risks misinterpretation. This practice validates care, crucial for nursing documentation integrity.
A community health nurse is assessing client's urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?
- A. The nurse added the Urine as the 2/3 part of the solution
- B. The nurse heats the test tube after adding 1/3 part acetic acid
- C. The nurse heats the test tube after adding 2/3 part of Urine
- D. The nurse determines abnormal result if she noticed that the test tube becomes cloudy
Correct Answer: B
Rationale: Acetic acid tests protein cloudiness not glucose; heating only acid (no urine) is wrong. Urine (2/3), heating with urine, cloudiness (protein) are correct. Nurses need correction e.g., purpose for accuracy, per procedure.
Which of the following is recognized for developing the concept of HIGH LEVEL WELLNESS?
- A. Erikson
- B. Madaw
- C. Peplau
- D. Dunn
Correct Answer: D
Rationale: Halbert Dunn's High-Level Wellness (1950s) concept frames health as maximizing potential within environmental limits e.g., thriving despite chronic illness. Unlike Erikson's stages, Madaw (unknown), or Peplau's relations, Dunn's idea influences nursing's focus on optimal functioning, not just disease absence, shaping wellness programs.