Nokea
Which of the following statement best describe subjective data?
- A. Measurable by the nurse
- B. Reported by the client
- C. Always accurate
- D. A physical finding
Correct Answer: B
Rationale: Subjective data is reported by the client (B), per assessment e.g., pain level. Not measurable (A), not always accurate (C), not physical (D) client-based. B best defines subjective's source, making it correct.
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When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?
- A. Position the client with the head of the bed elevated to 30° prior to insertion
- B. Measure the tube from the client's nose to the earlobe to the xiphoid process
- C. Lubricate the entire length of the tube with water-soluble lubricant
- D. Instruct the client to cough during insertion
Correct Answer: B
Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.
A patient about to undergo abdominal inspection is best placed in which of the following positions?
- A. Prone
- B. Trendelenburg
- C. Supine
- D. Side-lying
Correct Answer: C
Rationale: Supine allows full abdominal exposure for inspection.
The nurse avoided a romantic tie with Mr. Gary. This is an example of?
- A. Professional boundaries
- B. Cultural sensitivity
- C. Justice
- D. Fidelity
Correct Answer: A
Rationale: Avoiding romance is professional boundaries (A) keeping limits, per ethics. Sensitivity (B) culture, justice (C) fairness, fidelity (D) promises not boundary-specific. A fits the nurse's ethical distance, ensuring professionalism, making it correct.
A client with iron-deficiency anemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of foods high in iron.
- B. I should decrease my intake of foods high in iron.
- C. I should increase my intake of foods high in calcium.
- D. I should decrease my intake of foods high in calcium.
Correct Answer: A
Rationale: The correct answer is A: 'I should increase my intake of foods high in iron.' Iron-deficiency anemia is managed by increasing the consumption of iron-rich foods to improve iron levels in the body. Foods high in iron include red meat, poultry, fish, beans, lentils, and iron-fortified cereals. Choices B, C, and D are incorrect because decreasing intake of iron-rich foods or increasing intake of calcium-rich foods would not address the deficiency in iron levels that characterizes iron-deficiency anemia.
Which of the following statement is TRUE about case management?
- A. Focuses on one visit
- B. Coordinates care for complex needs
- C. Only for acute care
- D. All of the above
Correct Answer: B
Rationale: Case management coordinates care for complex needs (B), per model e.g., chronic illness. Not one visit (A), not acute-only (C), not all (D) long-term focus. B truly defines case management's role, making it correct.