Nokea
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
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The physician has ordered a culture specimen from a client with a suspected urinary tract infection. The nurse is aware that the specimen should be obtained:
- A. From the first morning voiding
- B. Using a sterile cotton ball placed in the client's vaginal area
- C. From the client's indwelling catheter port
- D. During the client's midstream voiding
Correct Answer: D
Rationale: Midstream voiding provides a clean-catch urine specimen for UTI culture, minimizing contamination first voiding risks sediment, vaginal cotton is irrelevant, and catheter ports are for indwelling cases. Nurses instruct this technique, ensuring accurate pathogen identification, critical for effective treatment.
Provides a concise method of organizing and recording data about the client. It is a series of flip cards kept in portable file used in change of shift reports.
- A. Kardex
- B. Progress Notes
- C. SOAPIE
- D. Change of shift report
Correct Answer: A
Rationale: Kardex (A) is a concise, card-based system for shift reports, per nursing practice. Progress notes (B) detail chronologically, SOAPIE (C) structures per problem, shift reports (D) are verbal. A fits the portable file description, making it correct.
The nurse raised her fist to Mr. Gary who refused his medication. This is an example of?
- A. Malpractice
- B. Negligence
- C. Assault
- D. Battery
Correct Answer: C
Rationale: Raising a fist to Mr. Gary is assault (C) intentional threat, per law. Malpractice (A) and negligence (B) are care failures, battery (D) requires touch. C fits the threatening act, making it correct.
The nurse is caring for a client following a transurethral resection of the prostate (TURP). Which finding should be reported to the physician immediately?
- A. Bright red urine 12 hours post-op
- B. Urine output of 30 mL/hour
- C. Complaints of bladder spasms
- D. Temperature of 100.2°F
Correct Answer: A
Rationale: Bright red urine 12 hours post-TURP suggests active bleeding, abnormal beyond initial pink-tinged output, requiring immediate physician report low output, spasms, or mild fever are less urgent. Nurses flag this, as hemorrhage risks clot retention or shock, prompting irrigation or intervention.
Myra, 21 year old nursing student has difficulty sleeping. She told Nurse Budek 'I really think a lot about my x boyfriend recently' Budek told Myra 'And that causes you difficulty sleeping?' Which therapeutic technique is used in this situation?
- A. Reflecting
- B. Restating
- C. Exploring
- D. Seeking clarification
Correct Answer: D
Rationale: Budek's 'And that causes you difficulty sleeping?' seeks clarification (D), asking Myra to confirm the link between her ex and insomnia. Reflecting (A) mirrors feelings (e.g., 'You're upset?'). Restating (B) repeats (e.g., 'You think about him a lot?'). Exploring (C) probes broadly. Clarification ensures understanding, per therapeutic models, fitting Budek's intent, making D correct.