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When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?
- A. whoever is authorized by hospital policy
- B. the student nurse giving the client's care
- C. the student nurse's instructor
- D. any licensed nurse on duty
Correct Answer: A
Rationale: Hospital policy dictates who takes telephone orders, ensuring legal and safety compliance, typically a licensed nurse, not a student or instructor alone. This standard protects clients from errors by untrained personnel, aligning with nursing scope and institutional rules for accurate order execution.
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A client has a mean arterial blood pressure (MAP) of $97 \mathrm{mmHg}$ and an intracranial pressure (ICP) of $12 \mathrm{mmHg}$. What is the cerebral perfusion pressure (CPP) for this client?
- A. 75
- B. 85
- C. 97
- D. 109
Correct Answer: B
Rationale: CPP = MAP - ICP; 97 - 12 = 85 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP measures brain perfusion; 85 mmHg is within normal (60-100 mmHg), critical for assessing adequacy post-injury, per neurocritical care formulas.
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct Answer: B
Rationale: Axillary avoids the oral route post-surgery and is appropriate for a flushed, warm client.
Which of the following statement is NOT true about Hospice care?
- A. Offered to terminally ill client
- B. The client's family is included in the care
- C. Focuses on relieving symptoms
- D. Requires client to sign a DNR
Correct Answer: D
Rationale: Hospice cares for terminally ill (A), includes family (B), and relieves symptoms (C), per hospice philosophy. Requiring a DNR (D) isn't true preferred, not mandatory; care focuses on comfort, not resuscitation status. D's absolute requirement misaligns with flexibility, making it the untrue statement.
The nurse is teaching the parent of an infant client about common pediatric conditions. Which statement by the nurse about otitis media is correct?
- A. Otitis media usually occurs before your child experiences a primary bacterial infection.'
- B. Some causes of otitis media can be prevented by administering a vaccine to your child.'
- C. Ear infections are very contagious and can also spread within your child's body.'
- D. If your infant uses a pacifier, it can prevent the development of otitis media.'
Correct Answer: B
Rationale: Otitis media (OM), middle ear infection, is often bacterial (e.g., Streptococcus pneumoniae). The correct statement is B: vaccines like PCV13 prevent some causes by targeting pathogens. A is false; OM typically follows infections. C is wrong; OM isn't highly contagious or systemic. D is incorrect; pacifiers increase OM risk. Rationale: Vaccines reduce OM incidence by immunizing against common bacteria, a key preventive strategy per AAP guidelines, unlike the other statements which misrepresent etiology or prevention.
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.