Nokea
Which nursing actions would demonstrate the nurse’s understanding of the concept of providing safe care without using restraints (select all that apply)?
- A. Placing patients with fall risk in low beds.
- B. Making hourly rounds on patients to assess for pain and toileting needs.
- C. Applying a jacket vest loosely so the patient can turn but cannot climb out of bed.
- D. Placing a disruptive patient near the nurses’ station in a chair with a seat belt.
Correct Answer: B
Rationale: Low beds, frequent checks, and strategic placement reduce risks without resorting to physical restraints.
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Symptoms of an ectopic pregnancy include:
- A. Hematuria, pelvic pain, and dizziness
- B. Amenorrhea, pelvic pain, and vaginal spotting
- C. Constipation, nausea, and fainting
- D. Fallopian pain, nausea, and breast enlargement
Correct Answer: B
Rationale: Ectopic pregnancies often present with amenorrhea, pelvic pain, and vaginal spotting due to the abnormal implantation site.
What changes are seen in the skin during shock?
- A. Increased urine output
- B. Edema
- C. Hypertension
- D. Hypernatremia
Correct Answer: B
Rationale: Edema occurs due to excess fluid accumulation in the interstitial spaces, commonly seen in conditions like heart failure and kidney disease.
What should govern the nurse’s actions regarding Mr. West rubbing Mrs. West’s calf?
- A. Touch is an important method of communication
- B. It is important to involve family members in patient care
- C. Massage increases circulation, therefore reducing tenderness
- D. A thrombus becomes an embolus when dislodged
Correct Answer: D
Rationale: Massaging the leg could dislodge a clot, leading to complications.
A male nurse would be providing culturally competent care by requesting that a female nurse provide the care for which patient?
- A. Arab male
- B. Latino male
- C. Arab female
- D. African American female
Correct Answer: C
Rationale: In Arab culture, modesty and gender roles dictate that female caregivers attend to women, especially regarding intimate care.
What is the primary role of lubricating eye drops?
- A. Moisten the eyes
- B. Treat infections
- C. Correct refractive errors
- D. None of the above
Correct Answer: A
Rationale: Lubricating drops relieve dryness and discomfort by moisturizing the ocular surface.