Nokea
Which is most closely aligned with ethics?
- A. Morals
- B. Laws
- C. Statutes
- D. Client rights
Correct Answer: A
Rationale: Ethics is most closely aligned with morals , as both involve principles of right and wrong that guide behavior, whereas laws and statutes are legal frameworks, and client rights are specific entitlements.
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Which of the following actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.
- A. Have the client state his or her name.
- B. Check the name on the arm band with the name on the medication.
- C. Learn to recognize the client.
- D. Check the client's room number.
- E. Compare the date of birth on the client's chart to the date of birth on the client's armband.
Correct Answer: A,B,E
Rationale: Using two identifiers, such as the client's name, armband, and date of birth, ensures accurate medication administration. Room number and visual recognition are not reliable.
When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches?
- A. Questioning the client about how much alcohol she drinks.
- B. Confronting the client with the fact that she was intoxicated 2 days ago.
- C. Pointing out how alcohol has gotten her into trouble.
- D. Listening to what the client states and then asking her how she plans to stay sober.
Correct Answer: D
Rationale: This approach uses therapeutic communication, acknowledging the client's perspective and encouraging problem-solving, which is effective for addressing denial in alcohol dependency.
The registered nurse is observing a new nurse auscultate the breath sounds of a client. Which action by the new nurse should lead the registered nurse to determine that further teaching is needed?
- A. Uses the bell of the stethoscope
- B. Asks the client to sit straight up
- C. Places the stethoscope directly on the client's skin
- D. Encourages the client to breathe slowly and deeply through the mouth
Correct Answer: A
Rationale: The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client's skin, not over a gown or clothing.
Which of the following would be most important for the nurse to include in the teaching plan for a client who is taking phenelzine (Nardil)?
- A. Eating a normal amount of salt in the diet.
- B. Drinking 10 to 12 glasses of water each day.
- C. Allowing 10 days to achieve therapeutic effects.
- D. Avoiding foods high in tyramine.
Correct Answer: D
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods to prevent hypertensive crisis.
A client complains of a dull headache and dizziness and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide,50 mm Hg; and bicarbonate, 24 mEq/L. These findings indicate which of the following acid-base imbalances?
- A. Respiratory alkalosis
- B. Respiratory acidosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: A pH of 7.26 (acidic) with elevated CO2 (50 mm Hg) and normal bicarbonate (24 mEq/L) indicates respiratory acidosis, likely due to hypoventilation. Other imbalances do not match these values.