Nokea
When examining the client's abdomen, the nurse will most facilitate the examination by positioning the client in which of the following ways?
- A. supine with small pillows beneath knees and head
- B. semi-Fowler's position with knees extended
- C. sitting in the chair with legs elevated
- D. supine with arms extended and hands behind head
Correct Answer: A
Rationale: Supine with pillows under knees and head relaxes abdominal muscles, aiding examination, unlike semi-Fowler's, sitting, or arms-up positions. Nurses use this for effective assessment.
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The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?
- A. Arranging for the wheelchair
- B. Asking her family to visit
- C. Assisting her to sit out of bed in a chair qid
- D. Encouraging the use of an overhead trapeze
Correct Answer: D
Rationale: The trapeze promotes upper body strength and mobility, aiding recovery.
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
- A. Use sterile gloves when obtaining urine.
- B. Open the drainage bag and pour out the urine.
- C. Disconnect the catheter from the tubing and get urine.
- D. Aspirate urine from the tubing port using a sterile syringe.
Correct Answer: D
Rationale: Aspirating urine from the tubing port with a sterile syringe is the appropriate action for obtaining a sterile urine specimen from an indwelling catheter. This maintains the closed system's integrity, minimizing infection risk by avoiding exposure to external contaminants. The port is designed for sterile sampling, ensuring the specimen reflects bladder contents accurately for testing. Using sterile gloves aids asepsis but isn't the complete action; it supports the procedure, not defines it. Opening the drainage bag introduces bacteria, risking contamination and infection. Disconnecting the catheter breaks the sterile circuit, increasing urinary tract infection likelihood contrary to best practice. Aspiration via the port, paired with aseptic technique, upholds infection control standards, ensuring patient safety and reliable diagnostic results, making it the optimal nursing action.
Which of the following statement is TRUE about tertiary care?
- A. Provided by general practitioners
- B. Focuses on health promotion
- C. Highly specialized care
- D. All of the above
Correct Answer: C
Rationale: Tertiary care is highly specialized (C), per system e.g., surgery, rehab. Not by GPs (A), not promotion (B), not all (D) advanced focus. C truly defines tertiary's complexity, making it correct.
The nurse asked an aide to check Mr. Gary's vitals. This is an example of?
- A. Delegation
- B. Responsibility
- C. Malpractice
- D. Health policy
Correct Answer: A
Rationale: Asking an aide for vitals is delegation (A) task assignment, per definition. Responsibility (B) duty, malpractice (C) breach, policy (D) rules not delegation-specific. A fits the nurse's supervised task for Mr. Gary, making it correct.
The nurse and doctor jointly planned Mr. Gary's treatment. This is an example of?
- A. Collaboration
- B. Professionalism
- C. Health literacy
- D. Care transition
Correct Answer: A
Rationale: Joint planning with doctor is collaboration (A) working together, per definition. Professionalism (B) standards, literacy (C) understanding, transition (D) moves not joint-specific. A fits teamwork, making it correct.