Nokea
Which of the following nursing intervention is needed before teaching a client post spleenectomy deep breathing and coughing exercises?
- A. Tell the patient that deep breathing and coughing exercises is needed to promote good breathing, circulation and prevent complication
- B. Tell the client that deep breathing and coughing exercises is needed to prevent Thrombophlebitis, hydrostatic pneumonia and atelectasis
- C. Medicate client for pain
- D. Tell client that cooperation is vital to improve recovery
Correct Answer: C
Rationale: Medicating for pain (C) is needed before teaching post-splenectomy exercises; pain hinders participation, per nursing care. General benefits (A), specific risks (B), and cooperation (D) follow pain control. C ensures effective learning, making it correct.
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Which of the following statement best describe collaboration in nursing?
- A. Working alone
- B. Working with others for care
- C. A competitive task
- D. A one-time event
Correct Answer: B
Rationale: Collaboration is working with others for care (B), per nursing e.g., team goals. Not alone (A), not competitive (C), not one-time (D) joint effort. B best defines collaboration's teamwork, making it correct.
The nurse is caring for a client following a right total hip replacement. Which action by the nurse will help prevent dislocation of the prosthesis?
- A. Keeping the client's knees together at all times
- B. Placing the client in a supine position with the legs extended
- C. Placing a pillow between the client's legs when turning
- D. Encouraging the client to use the trapeze to pull himself up in bed
Correct Answer: C
Rationale: Placing a pillow between the legs during turning maintains abduction, preventing hip prosthesis dislocation post-right total hip replacement knees together adducts, supine extension risks posterior dislocation, and trapeze use is safe but unrelated. Nurses enforce this, ensuring joint stability, key for orthopedic recovery.
The nurse threatened to force Mr. Gary to take meds. This is an example of?
- A. Assault
- B. Battery
- C. Negligence
- D. Malpractice
Correct Answer: A
Rationale: Threatening to force meds is assault (A) intentional threat, per law. Battery (B) touch, negligence (C) lapse, malpractice (D) breach not threat-specific. A fits the nurse's menacing act toward Mr. Gary, making it correct.
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
- A. chest pain related to cough secondary to pneumonia
- B. self-care deficit related to activity intolerance secondary to sleep-pattern disturbance
- C. risk for altered family processes secondary to hospitalization
- D. self-esteem deficit situational
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.
Which of the following statement best describe quality improvement?
- A. A one-time fix
- B. Ongoing effort to enhance care
- C. A punishment for errors
- D. A financial strategy
Correct Answer: B
Rationale: Quality improvement is an ongoing effort to enhance care (B), per QI models e.g., PDSA cycles. Not one-time (A), not punishment (C), not just finance (D) continuous. B best defines QI's iterative nature, making it correct.