Nokea
Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct Answer: A
Rationale: Of the choices given, only staphylococcus is considered a normal resident of the body.
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The nurse manager is reviewing a list of serious reportable events that occurred in a hospital setting before submitting the list to an external agency. Which event should the nurse manager remove from the list before it is submitted?
- A. The nurse is seriously injured when touching the client during a cardioversion procedure.
- B. The client obtains a skin tear and abrasion while transferring from the bed to a wheelchair.
- C. The client has a hip fracture after wandering off the unit and falling down the stairs.
- D. The client has a cardiac arrest; the serum potassium level was low and not reported to the HCP.
Correct Answer: B
Rationale: A skin tear and abrasion are not considered serious reportable events, unlike the other options which involve serious injuries or failures.
The nurse working with elderly clients should keep in mind that falls are most likely to happen to elderly who are:
- A. in their 80s.
- B. living at home.
- C. hospitalized.
- D. living on only Social Security income.
Correct Answer: C
Rationale: Elder people are particularly prone to falling and incurring serious injury, especially in new situations and environments (such as the hospital).
A nurse has been ordered to administer Morphine to a patient. Which of the following effects is unrelated to Morphine's effects on the patient?
- A. Depressed function of the CNS
- B. Increased blood flow
- C. Decreased venous capacity
- D. Pain relief
Correct Answer: C
Rationale: Venous capacity increases with morphine use, not decreases, as it causes vasodilation.
A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
- A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves shaving her legs.'
- B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
- C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
- D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct Answer: C
Rationale: Patient confidentiality should be observed, especially in public places. The nurse should tell the nursing student do not discuss confidential information in public.
The hospitalized client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse do? Select all that apply.
- A. Assess the client's risk for a fall using a rating scale.
- B. Document that the client is frequently incontinent.
- C. Ensure an immediate response to the client's call light.
- D. Educate the client regarding fall prevention strategies.
- E. Place a note on the door stating, "bathroom every two hours."
- F. Request that the HCP prescribe placement of a urinary catheter.
Correct Answer: A,C,D
Rationale: A: Assessing fall risk is essential due to urgency. C: Prompt response to call light prevents rushing. D: Education on fall prevention is proactive. B is incorrect as incontinence cannot be assumed. E violates privacy. F is unnecessary and risky.