Nokea
Which of the following patients is at greatest risk for developing pressure ulcers?
- A. An alert, chronic arthritic patient treated with steroids and aspirin
- B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home
- C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula
- D. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed
Correct Answer: B
Rationale: Age, immobility, incontinence, and malnutrition heighten pressure ulcer risk.
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A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
- A. Writing down all assignments
- B. Making changes after evaluating the situation and having discussions with the staff
- C. Telling the staff nurses that she is making changes to benefit their performance
- D. Evaluating the clinical performance of each staff nurse in a private conference
Correct Answer: B
Rationale: Evaluating and discussing changes eases transition and builds trust.
Mr. Gary stopped his meds and used herbal treatment instead. This is an example of?
- A. Alternative therapy
- B. Complementary therapy
- C. Patient education
- D. Managed care
Correct Answer: A
Rationale: Stopping meds for herbs is alternative therapy (A) replacing conventional, per definition. Complementary (B) combines, education (C) teaches, managed (D) costs not replacement-specific. A fits full switch, making it correct.
The purpose of assessment is to:
- A. Establish a database concerning the client
- B. Delegate nursing responsibility
- C. Teach the client about his or her health
- D. Implement nursing care
Correct Answer: A
Rationale: Assessment's purpose is to establish a client database, collecting subjective (e.g., pain reports) and objective (e.g., blood pressure) data to understand health status comprehensively. This informs all nursing process steps diagnosis, planning, implementation, evaluation ensuring care is evidence-based. Delegating responsibility is a management task, not assessment's goal, which focuses on data, not task assignment. Teaching clients about health occurs later, using assessment findings, not defining its purpose. Implementing care follows planning, not assessment, which precedes action. By building a detailed picture e.g., a patient's asthma triggers assessment equips nurses to address needs accurately, making it the essential first step and primary purpose in delivering tailored, effective care.
Which of the following is NOT a contraindication in taking ORAL temperature?
- A. Quadriplegic
- B. Presence of NGT
- C. Dyspnea
- D. Nausea and Vomitting
Correct Answer: A
Rationale: Quadriplegia isn't an oral temp contraindication e.g., a paralyzed patient can hold a thermometer if alert. NGT (obstruction), dyspnea (breathing), and nausea (gagging) preclude it. Nurses opt for alternatives e.g., axillary per safety protocols.
The nurse administers cleansing enema. The common position for this procedure is...
- A. Sims left lateral
- B. Dorsal Recumbent
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sims left lateral allows easy access to the rectum and comfort during an enema.