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Which of the following is true about the NURSING CARE PLAN?
- A. It is nursing centered
- B. Rationales are supported by interventions
- C. Verbal
- D. Atleast 2 goals are needed for every nursing diagnosis
Correct Answer: A
Rationale: The nursing care plan is nursing-centered (A), focusing on nurse-led actions, per planning standards. Rationales support interventions (B) reverses logic, verbal (C) isn't typical, two goals (D) isn't required. A aligns with purpose, making it correct.
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The nurse recorded Mr. Gary's vitals in his chart. This is an example of?
- A. Documentation
- B. Standard precautions
- C. Health policy
- D. Patient education
Correct Answer: A
Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.
When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:
- A. Protect the patient from injury
- B. Insert an airway
- C. Elevate the head of the bed
- D. Withdraw all pain medications
Correct Answer: A
Rationale: Protecting an unconscious patient from injury is the top priority.
The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?
- A. Call a code.
- B. Administer a bronchodilator.
- C. Contact the health care provider.
- D. Disconnect the suction source from the catheter.
Correct Answer: D
Rationale: A stuck catheter with coughing and wheezing suggests obstruction or bronchospasm; disconnecting the suction source (D) is the priority to relieve pressure and attempt removal. Calling a code (A) or provider (C) delays action. Bronchodilators (B) treat wheezing but not the immediate issue. D is correct. Rationale: Disconnecting stops suction trauma, allowing catheter withdrawal and airway reassessment, a critical first step per emergency airway protocols.
When working as a licensed vocational nurse, you determine that your client scheduled for surgery does not understand the physician's earlier explanation of the surgery. The client is asking many questions about the risks and seems worried. Which of the following actions would be best on your part?
- A. Quickly explain the surgery procedures and the risks to the client.
- B. Cancel the surgery.
- C. Ask your supervising RN to explain the surgery procedure and its risks.
- D. Notify the physician.
Correct Answer: D
Rationale: When a client scheduled for surgery shows a lack of understanding and expresses concern, notifying the physician is the best action for a licensed vocational nurse. The physician, as the primary decision-maker and the one obtaining informed consent, has the responsibility to ensure the client fully comprehends the procedure, risks, and benefits. The nurse's role is to facilitate communication and advocate for the client's needs, not to independently explain complex medical details outside their scope or cancel the surgery, which exceeds their authority. Asking the supervising RN might help, but it delays direct resolution by the physician, who is legally accountable for ensuring consent is informed. This approach upholds the nurse's duty to prioritize client understanding and safety while respecting professional boundaries and legal standards.
The nurse is aware that the normal frequency of bowel sounds is
- A. 1-5 gurgles/minute
- B. 5-35 gurgles/minute
- C. 35-60 gurgles/minute
- D. 60-100 gurgles/minute
Correct Answer: B
Rationale: Normal bowel sounds are 5-35 gurgles/minute e.g., peristalsis per norms. Less (hypoactive), more (hyperactive) differ. Nurses count e.g., 1 minute for function, per standards.