Nokea
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.
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While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?
- A. crackles
- B. Rales
- C. adventitious sounds
- D. pleral friction rub
Correct Answer: C
Rationale: Continuous abnormal lung sounds are charted as adventitious, encompassing wheezes or rubs, unlike intermittent crackles or rales. Pleural rub is specific. Nurses document this for respiratory evaluation.
When working as a licensed vocational nurse, you determine that your client scheduled for surgery does not understand the physician's earlier explanation of the surgery. The client is asking many questions about the risks and seems worried. Which of the following actions would be best on your part?
- A. Quickly explain the surgery procedures and the risks to the client.
- B. Cancel the surgery.
- C. Ask your supervising RN to explain the surgery procedure and its risks.
- D. Notify the physician.
Correct Answer: D
Rationale: When a client scheduled for surgery shows a lack of understanding and expresses concern, notifying the physician is the best action for a licensed vocational nurse. The physician, as the primary decision-maker and the one obtaining informed consent, has the responsibility to ensure the client fully comprehends the procedure, risks, and benefits. The nurse's role is to facilitate communication and advocate for the client's needs, not to independently explain complex medical details outside their scope or cancel the surgery, which exceeds their authority. Asking the supervising RN might help, but it delays direct resolution by the physician, who is legally accountable for ensuring consent is informed. This approach upholds the nurse's duty to prioritize client understanding and safety while respecting professional boundaries and legal standards.
Which of the following nursing intervention is appropriate when an IV infusion infiltrates?
- A. Elevate the site
- B. Discontinue the infusion
- C. Attempt to flush the tube
- D. Apply warm, moist compress
Correct Answer: B
Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.
The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?
- A. 6
- B. 9
- C. 12
- D. 15
Correct Answer: A
Rationale: A Glasgow Coma Scale (GCS) score of 6 (A) indicates coma, defined as ≤8, reflecting minimal responsiveness (eye, verbal, motor). Scores of 9 (B) and 12 (C) suggest moderate injury. 15 (D) is normal. A is correct. Rationale: GCS ≤8 signifies severe brain dysfunction, often requiring intubation, a standard threshold in neurocritical care for coma classification and management.
Founder of the PNA
- A. Julita Sotejo
- B. Anastacia Giron Tupas
- C. Eufemia Octaviano
- D. Anesia Dionisio
Correct Answer: B
Rationale: Anastacia Giron-Tupas founded the Philippine Nurses Association in 1922 e.g., advocating licensure elevating Filipino nursing. Sotejo (educator), Octaviano, and Dionisio differ. Her leadership shaped national standards, a key milestone in local nursing's professional history.