Nokea
Which of the following statement is TRUE about evaluation in nursing process?
- A. First step of the process
- B. Determines if goals are met
- C. Only done once
- D. All of the above
Correct Answer: B
Rationale: Evaluation determines if goals are met (B), per process e.g., pain reduced? Not first (A, assessment), not once (C, ongoing), not all (D) outcome-focused. B truly defines evaluation's role, making it correct.
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What is nurse's primary critical observation when performing an assessment for determining an Apgar score?
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of Moro reflex
Correct Answer: A
Rationale: Apgar score assesses newborn vitality at 1 and 5 minutes post-birth across five criteria: heart rate, respiration, muscle tone, reflex, color. Heart rate (choice A) is primary; absent (<60 bpm = 0, <100 = 1, >100 = 2) dictates immediate resuscitation, making it the most critical. Respiratory rate (choice B) follows, but weak/absent breathing often ties to heart rate. Meconium (choice C) isn't scored directly, though it flags distress. Moro reflex (choice D) tests tone/reflex, secondary to vitals. A is correct, as heart rate drives initial intervention. Nurses prioritize it, ensuring rapid response to stabilize the infant.
A client is receiving 115 ml/hr of continuous IVF. The nurse noticed that the venipuncture site was red and swollen. Which of the following interventions would the nurse perform first?
- A. Stop the infusion
- B. Call the attending physician
- C. Slow that infusion to 20 ml/hr
- D. Place a cold towel on the site
Correct Answer: A
Rationale: Stopping the infusion is the nurse's first intervention when observing a red, swollen venipuncture site, as this may indicate phlebitis, infiltration, or infection. Halting the IV prevents further tissue damage or fluid extravasation, prioritizing patient safety. Redness and swelling suggest inflammation or leakage into surrounding tissue, requiring immediate cessation to assess severity and plan next steps, like site relocation or physician consultation. Calling the physician follows assessment, not precedes stopping the infusion, as the nurse acts within scope to mitigate harm first. Slowing the infusion might worsen damage if fluid is already escaping the vein. A cold towel could reduce swelling later but doesn't address the active infusion causing the issue. Stopping the infusion is the critical initial step, enabling evaluation and preventing complications, aligning with nursing's focus on prompt, protective action.
Which technique would be best in caring for a client following receiving a diagnosis of a stage IV tumor in the brain?
- A. Offering the client pamphlets on support groups for brain cancer
- B. Asking the client if there is anything he or his family needs
- C. Reminding the client that advances in technology are occurring everyday
- D. Providing accurate information about the disease and treatment options
Correct Answer: D
Rationale: Accurate information empowers the client and family to make informed decisions.
The nurse is caring for a client with a diagnosis of cirrhosis who has developed esophageal varices. Which of the following foods should be removed from the client's diet?
- A. Custard
- B. Mashed potatoes
- C. Spinach
- D. Raisins
Correct Answer: C
Rationale: Spinach should be removed from the diet of a client with cirrhosis and esophageal varices, as its rough texture and high vitamin K content could irritate fragile varices or alter clotting, risking rupture and hemorrhage a critical concern in advanced liver disease. Custard, mashed potatoes, and raisins are softer and safer, lacking this risk. Nurses adjust diets to minimize esophageal trauma, teaching clients to avoid coarse foods, protecting against bleeding episodes that could require urgent interventions like banding or transfusion.
The nurse reviewed Mr. Gary's care to reduce errors. This is an example of?
- A. Quality improvement
- B. Patient-centered care
- C. Nursing informatics
- D. Health promotion
Correct Answer: A
Rationale: Reviewing care to reduce errors is quality improvement (A) enhancing processes, per definition. Patient-centered (B) tailors, informatics (C) tech, promotion (D) well-being not error-focused. A fits QI's aim, making it correct.