Nokea
Which of the following statement is NOT true about care transition?
- A. Moving between care settings
- B. Involves communication
- C. Only occurs in hospitals
- D. May affect outcomes
Correct Answer: C
Rationale: Care transition moves between settings (A), involves communication (B), affects outcomes (D) 'only in hospitals' (C) isn't true, includes home, per process. C's limit fails, making it untrue.
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The physician has ordered a low-potassium diet for a client with renal failure. Which food should be limited due to its potassium content?
- A. Broccoli
- B. Bananas
- C. Lean beef
- D. White rice
Correct Answer: B
Rationale: Bananas, with ~400-450 mg potassium per fruit, must be limited on a low-potassium diet in renal failure, as impaired kidneys can't excrete excess, risking hyperkalemia broccoli's moderate, beef and rice's low potassium fit better. Nurses teach this, preventing cardiac issues, tailoring diets for renal safety.
Rommel told Budek, 'Do you think Im crazy?' Budek responded, 'Do you think your crazy?' Budek uses what example of therapeutic communication?
- A. Reflecting
- B. Restating
- C. Exploring
- D. Seeking clarification
Correct Answer: A
Rationale: Budek's 'Do you think you're crazy?' is reflecting (A), redirecting Rommel's question to explore his feelings or self-perception. Restating (B) repeats verbatim (e.g., 'You think you're crazy?'). Exploring (C) digs deeper (e.g., 'Why do you ask?'). Clarification (D) seeks meaning. Reflecting, per Peplau, fosters self-reflection, apt for Rommel's doubt, making A correct.
The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning a morphine order for pancreatitis exemplifies the client advocate role, where nurses safeguard patient well-being. Morphine can worsen pancreatitis by causing sphincter of Oddi spasm, unlike safer options like meperidine. By challenging this, the nurse protects the client from harm, a duty rooted in ethical codes like the ANA's. Change agents modify behaviors, case managers coordinate, and collaborators work jointly, but advocacy uniquely prioritizes patient safety over compliance. In practice, this might involve consulting the doctor for an alternative, ensuring care aligns with the patient's best interest, a critical nursing responsibility.
A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
- A. Supine with head turned to the right
- B. Prone with the head straight
- C. Semi-Fowler's at 30 degrees
- D. High Fowler's at 90 degrees
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
A community health nurse is assessing client's urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?
- A. The nurse added the Urine as the 2/3 part of the solution
- B. The nurse heats the test tube after adding 1/3 part acetic acid
- C. The nurse heats the test tube after adding 2/3 part of Urine
- D. The nurse determines abnormal result if she noticed that the test tube becomes cloudy
Correct Answer: B
Rationale: Acetic acid tests protein cloudiness not glucose; heating only acid (no urine) is wrong. Urine (2/3), heating with urine, cloudiness (protein) are correct. Nurses need correction e.g., purpose for accuracy, per procedure.