Nokea
When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?
- A. Competitive board games with older children
- B. Playing with their own toys along side with other children
- C. Playing alone with hand held computer games
- D. Playing cooperatively with other preschoolers
Correct Answer: D
Rationale: Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.
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Signs of internal bleeding include all of the following except:
- A. painful or swollen extremities.
- B. a tender, rigid abdomen.
- C. vomiting bile.
- D. bruising.
Correct Answer: C
Rationale: Vomiting bile is usually not a sign of internal bleeding. Painful or swollen extremities, a tender, rigid abdomen, and bruising are indicative of internal bleeding.
Pressure is being exerted to the client's foot ulcer from the bottom bed guard, and the client needs to be pulled up in bed. The client weighs 130 lb. Which action by the nurse is best when no one is available to assist the nurse?
- A. Wait until sufficient help is available to pull up and reposition the client in bed
- B. Place pillows over the bed guard and elevate both of the client's legs on the pillows
- C. Place the bed in Trendelenburg position to relieve the pressure and then wait for help
- D. Use a slight Trendelenburg position, have the client lift the heels, and pull the client up in bed
Correct Answer: D
Rationale: Using a slight Trendelenburg position leverages gravity to assist in moving a lightweight client safely, while lifting the heels prevents friction injury. Waiting for help (A) delays relief, pillows (B) risk sliding, and full Trendelenburg (C) may compromise respiration.
The non-English-speaking hospitalized client begins to enter a room with the sign illustrated. Which intervention should the observing nurse implement?
- A. Inform the client's assigned nurse that the client is back in his or her room.
- B. Intercept the client and check the client's name band for a room number.
- C. Stop the client and ask for his or her name and the assigned room number.
- D. Ask the nearby UAP to help the client back into the room with the sign posted.
Correct Answer: B
Rationale: Intercepting and checking the name band ensures the client does not enter a radiation therapy room, accounting for the language barrier.
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
- A. Biofeedback
- B. Deep breathing
- C. Distraction
- D. Imagery
Correct Answer: B
Rationale: Deep breathing. Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
A risk management program within a hospital is responsible for all of the following except:
- A. identifying risks.
- B. controlling financial loss due to malpractice claims.
- C. making sure that staff follow their job descriptions.
- D. analyzing risks and trends to guide further interventions or programs.
Correct Answer: C
Rationale: Risk management is an organizationwide program to identify risks and control incidents and legal liability. It does not have any direct supervisory or management responsibility for staff.