Nokea
Which of the following statement is TRUE about safety in health care?
- A. Errors are unavoidable
- B. Focuses on preventing harm
- C. Only applies to surgery
- D. All of the above
Correct Answer: B
Rationale: Safety focuses on preventing harm (B), per standards e.g., protocols reduce risks. Errors can be minimized (A), not surgery-only (C), not all (D) broad scope. B truly defines safety's priority, making it correct.
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A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?
- A. Prepare for reintubation.
- B. Call the health care provider.
- C. Call the rapid response team.
- D. Check the client for spontaneous breathing.
Correct Answer: D
Rationale: If a tracheostomy tube is dislodged, checking for spontaneous breathing (D) is the priority to assess airway patency and oxygenation need. Preparing for reintubation (A) or calling teams (B, C) follows. D is correct. Rationale: Assessing breathing determines if immediate reinsertion or oxygenation is urgent, guiding next steps per respiratory emergency standards, ensuring patient stability first.
Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger 'That is an unacceptable behavior Roger, Stop and go to your room now.' The situation is most likely in what phase of NPR?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: This scenario fits the Working phase (C). Roger's agitation and Aida's response setting boundaries suggest an established relationship where interventions address behaviors. Pre-Orientation (A) is pre-contact, Orientation (B) builds trust, not confrontation, and Termination (D) ends care. In Peplau's Working phase, the nurse actively helps the client manage issues, as Aida does here, making C the likely phase.
You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
- A. Stop working on these goals, as evaluation is the last step.
- B. Assess client's motivation for complying with the care plan.
- C. Reassess problem and then review care plan and revise as needed.
- D. Determine if the client has a knowledge deficit causing nonattainment.
Correct Answer: C
Rationale: When goals aren't met during evaluation, reassessing the problem and revising the care plan is the best action. This step identifies why outcomes like reduced swelling failed, perhaps due to an outdated intervention, and adjusts accordingly. Stopping assumes evaluation ends the process, ignoring its cyclical nature. Assessing motivation or knowledge deficits might inform revisions but isn't comprehensive without reassessment. This approach ensures care evolves with the client's condition, maintaining relevance and efficacy in the nursing process.
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria is linked to right-sided heart failure, where fluid shifts from edematous tissues to the bloodstream at night, increasing urine output as the heart struggles to pump against venous congestion. Shortness of breath and crackles typify left-sided failure, while daytime oliguria isn't specific. Nurses monitor this to assess heart function, guiding fluid management and diuretic use effectively.
Which of the following statement best describe battery in nursing?
- A. A verbal threat
- B. Unconsented physical contact
- C. A legal fine
- D. A care plan
Correct Answer: B
Rationale: Battery is unconsented physical contact (B), per law e.g., touching without permission. Not threat (A, assault), not fine (C), not plan (D) contact-based. B best defines battery's violation, like touching Mr. Gary against will, making it correct.