Nokea
Which of the following statement best describe a living will?
- A. A legal document that states what the client wants to happen should he become incapacitated
- B. A legal document assigning a proxy to make a decision
- C. A legal document that prohibits CPR
- D. A legal document that assigns properties to relatives
Correct Answer: A
Rationale: A living will is a legal document stating care wishes if incapacitated (A), per advance directive definitions e.g., ventilation preferences. Proxy assignment (B) is a power of attorney, CPR prohibition (C) is DNR, property (D) a will. A best captures its intent, making it correct.
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The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
- A. Suctioning is required frequently.
- B. Aspiration of gastric contents occurs when suctioning.
- C. The client's skin and mucous membranes are light pink.
- D. Excessive secretions are suctioned from a tracheostomy.
Correct Answer: B
Rationale: Tracheoesophageal fistula (TEF), a rare tracheostomy complication, involves an abnormal connection between trachea and esophagus. Aspiration of gastric contents during suctioning (B) is a definitive sign, indicating esophageal leakage into the airway. Frequent suctioning (A) or excessive secretions (D) are nonspecific. Pink skin (C) reflects good oxygenation, not TEF. B is correct. Rationale: TEF allows gastric contents to enter the trachea, detected during suctioning, requiring urgent intervention like tube adjustment or surgery, distinct from routine secretion issues, per critical care nursing.
Which statement best describes the effects of immobility in children?
- A. Immobility prevents the progression of language and fine motor development
- B. Immobility in children has similar physical effects to those found in adults
- C. Children are more susceptible to the effects of immobility than are adults
- D. Children are likely to have prolonged immobility with subsequent complications
Correct Answer: B
Rationale: Children experience similar physical immobility effects as adults, like atrophy and demineralization.
A client's wife has been informed by the physician that her spouse has a permanent C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. The nurse has conflicting emotions about how to handle the situation and is experiencing:
- A. autonomy.
- B. moral distress.
- C. moral doubt.
- D. moral courage.
Correct Answer: B
Rationale: The nurse's conflict between truth-telling and the wife's request is moral distress (B), feeling unable to act ethically. Autonomy (A) is patient rights. Doubt (C) is uncertainty. Courage (D) is acting despite fear. B is correct. Rationale: Moral distress arises from ethical dilemmas, common in nursing when values clash, per ethics frameworks, requiring resolution.
Which of the following statement best describe nursing code of ethics?
- A. Hospital-specific rules
- B. Moral guidelines for nurses
- C. A legal contract
- D. A patient request
Correct Answer: B
Rationale: Nursing code of ethics is moral guidelines for nurses (B), per ANA e.g., duty, respect. Not hospital (A), not contract (C), not request (D) profession-wide. B best defines its ethical framework, guiding Mr. Gary's nurse, making it correct.
A client has a new diagnosis of lactose intolerance and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?
- A. You should avoid foods that contain lactose.
- B. You should increase your intake of high-fiber foods.
- C. You should avoid foods that contain gluten.
- D. You should increase your intake of dairy products.
Correct Answer: A
Rationale: The correct statement for the nurse to include in teaching a client with lactose intolerance is to avoid foods that contain lactose. Lactose intolerance results from the body's inability to digest lactose, a sugar found in dairy products. By avoiding foods containing lactose, the client can manage symptoms and prevent complications associated with lactose intolerance. Choices B, C, and D are incorrect. Increasing intake of high-fiber foods (choice B) may be beneficial for general health but is not directly related to lactose intolerance. Avoiding gluten (choice C) is necessary for individuals with celiac disease, not lactose intolerance. Increasing intake of dairy products (choice D) would worsen symptoms in individuals with lactose intolerance due to the lactose content.