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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Which of the following describes a 'comfort zone'?
- A. The area where closeness is not required during nursing care.
- B. The area that encompasses up to 5 to 7 feet from the client.
- C. The area that,when intruded upon does not create any kind of anxiety.
- D. The area where a client is well draped.
Correct Answer: B
Rationale: A comfort zone typically refers to the personal space around an individual, which varies but generally extends up to 5-7 feet.
Bob is diagnosed with idiopathic thrombocytopenic purpura (ITP). You realize that he has an increased risk of bleeding and you must monitor
- A. WBC and bleeding time.
- B. Prothrombin time (PT) and partial thromboplastin time (PTT).
- C. Platelet count and RBC.
- D. Iron and ferritin levels.
Correct Answer: C
Rationale: Low platelet count increases the risk of bleeding in ITP.
A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
- A. Kussmaul respirations
- B. Apneustic respirations
- C. Cheyne-Stokes respirations
- D. Stridor
Correct Answer: C
Rationale: The correct answer is C: Cheyne-Stokes respirations. This breathing pattern is characterized by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations (A) are deep and rapid breathing associated with metabolic acidosis. Apneustic respirations (B) are characterized by prolonged inhalation and short, insufficient exhalation. Stridor (D) is a high-pitched, noisy breathing sound caused by obstructed air flow in the upper airway, not associated with the described breathing pattern.
To offer the most effective program with the best outcomes, the nurses should initially
- A. Search for an article that describes nursing interventions that are effective for smoking cessation
- B. Develop a clinical question that will allow them to compare different cessation methods during the program
- C. Keep comprehensive records that detail each patient’s progress and ultimate outcomes from participation in the program
- D. Use evidence-based clinical practice guidelines developed from reviews of randomized controlled trials of smoking cessation methods
Correct Answer: D
Rationale: Using evidence-based guidelines ensures the program is grounded in proven methodologies, leading to better outcomes.
Cognitive changes include memory problems, confusion, and disorientation. These changes:
- A. Occur in 75% of patients over age 65
- B. Are not a normal part of aging
- C. Are due to enhanced cerebral blood flow
- D. Cause senile plaques and neurofibrillary tangles
Correct Answer: B
Rationale: Cognitive decline is not a normal part of aging; it may indicate underlying conditions such as dementia or Alzheimer's disease. Normal aging involves mild forgetfulness but not significant impairment.