Nokea
Which of the following statement is TRUE about patient safety?
- A. Only about medication
- B. Prevents harm in care
- C. Not a nursing concern
- D. All of the above
Correct Answer: B
Rationale: Patient safety prevents harm in care (B), per standards e.g., fall prevention. Not just meds (A), is nursing concern (C), not all (D) broad focus. B truly defines safety's aim, 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.
Which of the following urine color is considered normal?
- A. Dark amber
- B. Yellow, Cloudy
- C. Light Yellow, Amber
- D. Slightly pale yellow
Correct Answer: D
Rationale: Slightly pale yellow is normal e.g., hydrated urine per standards. Dark amber (dehydration), yellow cloudy (infection), light yellow amber (concentrated) differ. Nurses assess e.g., hydration for health, per norms.
During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply.
- A. Cortisol
- B. Thyroid
- C. Estrogen
- D. Testosterone
Correct Answer: B
Rationale: Increased BMR with elevated temperature suggests thyroid (B) excess (hyperthyroidism), boosting metabolism. Cortisol (A) affects stress, not BMR primarily. Estrogen (C) and testosterone (D) influence other systems. B is correct. Rationale: Thyroid hormones (T3, T4) directly raise BMR and heat, a classic endocrine imbalance, per physiology, unlike other hormones with indirect effects.
Myra, 21 year old nursing student has difficulty sleeping. She told Nurse Budek 'I really think a lot about my x boyfriend recently' Budek told Myra 'And that causes you difficulty sleeping?' Which therapeutic technique is used in this situation?
- A. Reflecting
- B. Restating
- C. Exploring
- D. Seeking clarification
Correct Answer: D
Rationale: Budek's 'And that causes you difficulty sleeping?' seeks clarification (D), asking Myra to confirm the link between her ex and insomnia. Reflecting (A) mirrors feelings (e.g., 'You're upset?'). Restating (B) repeats (e.g., 'You think about him a lot?'). Exploring (C) probes broadly. Clarification ensures understanding, per therapeutic models, fitting Budek's intent, making D correct.
The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?
- A. pH of 7.35, Pco2 of $50 \mathrm{~mm} \mathrm{Hg}, \mathrm{HCO} 3- of $32 \mathrm{mEq} / \mathrm{L}$
- B. pH of 7.45, Pco2 of $35 \mathrm{~mm} \mathrm{Hg}, \mathrm{HCO} 3- of $22 \mathrm{mEq} / \mathrm{L}$
- C. pH of 7.38, Pco2 of $45 \mathrm{~mm} \mathrm{Hg}, \mathrm{HCO} 3- of $32 \mathrm{mEq} / \mathrm{L}$
- D. pH of 7.48, Pco2 of $40 \mathrm{~mm} \mathrm{Hg}, \mathrm{HCO} 3- of $36 \mathrm{mEq} / \mathrm{L}$
Correct Answer: D
Rationale: Metabolic alkalosis features high pH (>7.45) and elevated HCO3- (>26 mEq/L) with normal Pco2 (35-45 mm Hg). Option D (pH 7.48, Pco2 40, HCO3- 36) fits this, indicating excess base. A is respiratory acidosis. B is normal. C is compensated. D is correct. Rationale: High HCO3- from vomiting or diuretics causes alkalosis, uncompensated here, per ABG interpretation principles.