Nokea
Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair?
- A. Bend at the waist and place arms under the client's arms and lift
- B. Face the client, bend knees and place hands on client's forearm and lift
- C. Spread his or her feet apart
- D. Tighten his or her pelvic muscles
Correct Answer: B
Rationale: Facing the client, bending knees, and using forearms provides a wide base and proper body mechanics for safe lifting.
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Which of the following statement is TRUE about tertiary care?
- A. Provided by general practitioners
- B. Focuses on health promotion
- C. Highly specialized care
- D. All of the above
Correct Answer: C
Rationale: Tertiary care is highly specialized (C), per system e.g., surgery, rehab. Not by GPs (A), not promotion (B), not all (D) advanced focus. C truly defines tertiary's complexity, making it correct.
What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?
- A. A cotton ball
- B. A penlight
- C. An ophthalmoscope
- D. A tongue depressor and flashlight
Correct Answer: D
Rationale: Cranial nerves 9 and 10 (glossopharyngeal and vagus) are assessed with a gag reflex, requiring a tongue depressor and light.
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.
Which of the following provides that nurses must be a member of a national nurse organization?
- A. R.A 877
- B. 1981 Code of ethics approved by the house of delegates
- C. R.A 7164
- D. PNA memorandum no. 22 series of 1922
Correct Answer: B
Rationale: The 1981 Philippine Nursing Code of Ethics mandates national organization membership (PNA) e.g., ensuring accountability. R.A. 877 (old law), R.A. 7164 (1991 law), and PNA memos differ. This reflects nursing's collective duty, reinforcing unity and ethical standards in practice.
A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending:
- A. Pulmonary egophony
- B. Amniotic fluid embolism
- C. Anaphylaxis
- D. Bronchospasm
Correct Answer: C
Rationale: Sudden breathing difficulty, weakness, and nausea during antibiotic administration suggest a severe allergic reaction, known as anaphylaxis. This life-threatening condition involves systemic histamine release, causing airway constriction, hypotension, and gastrointestinal distress. Pulmonary egophony relates to lung sound changes, not systemic symptoms. Amniotic fluid embolism presents with cardiovascular collapse and bleeding, not primarily nausea. Bronchospasm is airway narrowing but lacks the broader symptoms here. Immediate recognition of anaphylaxis prompts epinephrine administration and airway support, critical for maternal and fetal survival in labor.