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Which intervention should the nurse implement to prevent contractures in a patient who is immobile?
- A. Encouraging frequent changes in position
- B. Applying heat packs to stiff joints
- C. Administering muscle relaxants
- D. Using soft restraints to immobilize the extremities
Correct Answer: A
Rationale: Frequent position changes prevent contractures in immobile patients by keeping joints mobile and reducing muscle shortening risks. Heat or relaxants offer relief but don't address root immobility, and restraints worsen stiffness. Nurses use this to maintain range of motion, ensuring flexibility and function, a proactive measure against permanent musculoskeletal damage in prolonged stillness.
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Among the following statements, which should be given the HIGHEST priority?
- A. Client is in extreme pain
- B. Client's blood pressure is 60/40
- C. Client's temperature is 40 deg. Centigrade
- D. Client is cyanotic
Correct Answer: B
Rationale: BP 60/40 (B) is highest priority; severe hypotension threatens perfusion, per ABCs (circulation). Pain (A), fever (C), and cyanosis (D) are urgent but secondary to life-threatening shock. B demands immediate action, making it correct.
A client with hyperkalemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of potassium-rich foods.
- B. I should decrease my intake of potassium-rich foods.
- C. I should increase my intake of sodium-rich foods.
- D. I should decrease my intake of sodium-rich foods.
Correct Answer: B
Rationale: Correct! Hyperkalemia is a condition characterized by high levels of potassium in the blood. To manage hyperkalemia, it is essential to decrease the intake of potassium-rich foods since excess potassium can worsen the condition. By understanding the need to decrease potassium-rich foods, the client shows comprehension of the dietary management required for hyperkalemia. Choice A is incorrect because increasing potassium-rich foods would exacerbate hyperkalemia. Choice C is incorrect since increasing sodium-rich foods is unrelated to managing hyperkalemia and could potentially lead to other health issues. Choice D is incorrect as decreasing sodium-rich foods is not the primary focus when managing hyperkalemia.
Caring is healing, it is communicated through the consciousness of the nurse to the individual being cared for. It allows access to higher human spirit.
- A. Benner
- B. Watson
- C. Leininger
- D. Swanson
Correct Answer: B
Rationale: Jean Watson's Human Caring Theory, developed in the 1970s, defines caring as a healing force transmitted through the nurse's consciousness, connecting to the patient's spirit. She sees nursing as transcending physical acts, fostering openness to a higher human essence. Unlike Benner's skill progression, Leininger's cultural focus, or Swanson's process model, Watson's approach is deeply philosophical, emphasizing transpersonal caring moments like a nurse's empathy soothing a dying patient's fear. Her 10 Carative Factors (e.g., instilling hope) guide this spiritual exchange, influencing holistic nursing practices globally, particularly in palliative care, where emotional and existential support is paramount.
A group of nursing students has attended a presentation about the National Student Nurses' Association (NSNA). Which statement by the group indicates that they have understood the information presented?
- A. The NSNA contributes to the improvement of public health
- B. The organization provides programs of current professional interest
- C. It is run by a group of registered nurses
- D. It is funded by the national government
Correct Answer: B
Rationale: The National Student Nurses' Association (NSNA) is a student-led organization designed to support nursing students' professional development, and understanding its purpose is key for students. The correct statement, that it provides programs of current professional interest, reflects its role in offering educational events, leadership opportunities, and resources tailored to students' needs, preparing them for their future careers. The NSNA does not primarily focus on improving public health, which is more aligned with bodies like the Commission on Collegiate Nursing Education. It is not run by registered nurses but by students themselves, emphasizing peer leadership and engagement. Additionally, it is student-funded through membership dues, not supported by the national government. This distinction highlights the NSNA's unique position as a grassroots organization fostering professional growth, networking, and advocacy among nursing students, ensuring they are well-equipped to enter the profession with relevant skills and knowledge.
A client has a tracheostomy and requires suctioning. Which of the following actions should be taken?
- A. Hyperoxygenate the client before suctioning
- B. Insert the catheter while exhalation
- C. Apply suction after inserting the catheter
- D. Limit suctioning to no more than 15 seconds
Correct Answer: A
Rationale: Hyperoxygenating the client before suctioning is crucial to prevent hypoxia during the procedure. By using a manual resuscitation bag with 100% oxygen, the nurse should provide several breaths to the client to ensure sufficient oxygenation before starting suctioning. This approach helps maintain oxygen levels and decreases the risk of hypoxia, which may arise when suctioning interrupts the normal respiratory process. Choices B, C, and D are incorrect because inserting the catheter during exhalation, applying suction while inserting the catheter, and limiting suctioning to 15 seconds do not address the priority of hyperoxygenating the client to prevent hypoxia.