Nokea
Which of the following statement best describe beneficence?
- A. Doing good for the client
- B. Fairness and equality
- C. Respecting client's decision
- D. Keeping promises
Correct Answer: A
Rationale: Beneficence is doing good for the client (A), per ethics acting in their best interest (e.g., pain relief). Fairness (B) is justice, decision respect (C) autonomy, promises (D) fidelity. A best captures beneficence's intent, making it correct.
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The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
- A. Rectus femoris muscle
- B. Vastus lateralis muscle
- C. Deltoid muscle
- D. Dorsogluteal muscle
Correct Answer: B
Rationale: The vastus lateralis muscle is the preferred site for vitamin K injection in newborns, offering a large, safe muscle mass away from nerves and vessels, standard for intramuscular prophylaxis against hemorrhagic disease. Rectus femoris is smaller, deltoid underdeveloped, and dorsogluteal risky near sciatic nerve. Nurses use this site for efficacy and safety, teaching parents its purpose in clotting support.
An infant is born precipitously outside the labor room. What should the nurse do first?
- A. Tie and cut the umbilical cord
- B. Establish an airway for the newborn
- C. Ascertain the condition of the uterine fundus
- D. Arrange transport for the mother and infant to the birthing unit
Correct Answer: B
Rationale: Precipitous birth outside controlled settings demands urgent action. Tying/cutting the cord (choice A) is secondary; delay poses no immediate risk unless bleeding occurs. Establishing an airway (choice B) is first, as newborns must breathe independently clearing mucus or stimulating crying ensures oxygenation, critical within the golden minute. Checking the fundus (choice C) assesses maternal bleeding, a later priority. Transport (choice D) follows stabilization. B is correct, per neonatal resuscitation guidelines. Nurses clear airways, warm the infant, and then address cord and maternal needs, ensuring survival.
An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?
- A. Perform physical assessment
- B. Have the client rate his pain on the smiley pain rating scale
- C. Active listening on what the patient says
- D. Observe the client's behavior
Correct Answer: B
Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.
A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?
- A. Prepare for reintubation.
- B. Call the health care provider.
- C. Call the rapid response team.
- D. Check the client for spontaneous breathing.
Correct Answer: D
Rationale: If a tracheostomy tube is dislodged, checking for spontaneous breathing (D) is the priority to assess airway patency and oxygenation need. Preparing for reintubation (A) or calling teams (B, C) follows. D is correct. Rationale: Assessing breathing determines if immediate reinsertion or oxygenation is urgent, guiding next steps per respiratory emergency standards, ensuring patient stability first.
How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?
- A. 5
- B. 10
- C. 15
- D. 30
Correct Answer: D
Rationale: After activity, smoking, or caffeine e.g., raising BP 30 minutes rest ensures accuracy, per AHA guidelines. Shorter times (5-15 min) risk false highs. Nurses enforce this e.g., post-exercise delay for reliable readings, standard in clinical assessment protocols.