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.
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that
- A. a referral is needed to the psychiatrist who is to provide the client with answers
- B. the client has a right to know about the prescribed medications
- C. such education is an independent decision of the individual nurse whether or not to teach clients about their medications
- D. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
Correct Answer: B
Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would best measure learning?
- A. Performance on written tests
- B. Responses to verbal questions
- C. Completion of a mailed survey
- D. Reported behavioral changes
Correct Answer: D
Rationale: Reported behavioral changes. If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.
A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?
- A. A 76-year-old client with severe depression
- B. A middle-aged client with an obsessive compulsive disorder
- C. An adolescent with dehydration and anorexia
- D. A young adult who is a heroin addict in withdrawal with hallucinations
Correct Answer: B
Rationale: The UAP can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition.
The experienced nurse is instructing the new nurse on client safety. Which statement made by the new nurse should the experienced nurse correct?
- A. "It is very important for school-aged children to be taught_statistics related to sports."
- B. "The leading causes of death in young adults are due to substance abuse and suicide."
- C. "Older adults especially should be asked whether they have ever accidentally fallen at home."
- D. "Preschooler activity should be monitored because falls are a major cause of nonfatal injuries."
Correct Answer: B
Rationale: The leading cause of death in young adults is motor vehicle accidents, not substance abuse and suicide, which requires correction.