Nokea
Which of the following tasks may be delegated to unlicensed assistive personnel?
- A. Cleansing a wound with peroxide
- B. Irrigating a colostomy
- C. Assisting with performing incentive spirometry
- D. Removing a saline-lock IV
Correct Answer: C
Rationale: The correct answer is C. Assisting with performing incentive spirometry can be delegated to unlicensed assistive personnel (UAP) as it involves a non-invasive procedure that does not require specialized training or licensure. UAP can help patients with using the incentive spirometer to improve lung function under the supervision of a licensed healthcare provider. Choices A, B, and D involve tasks that require specific skills and knowledge to prevent complications, hence should be performed by licensed healthcare professionals.
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Research participants are involved in a trial that incidentally separates them into two groups. One group receives an intervention, while the other group does not. Both groups are compared for outcomes. What type of research method is this?
- A. Experimental design
- B. Double-blind experiment
- C. Randomized controlled trial
- D. Repeated measures design
Correct Answer: C
Rationale: The correct answer is C: Randomized controlled trial (RCT). In an RCT, participants are randomly assigned to either the intervention group or the control group, ensuring that both groups are similar at the start of the trial. This minimizes bias and allows for comparing the outcomes of the intervention group with the control group. This design helps establish a cause-effect relationship between the intervention and the outcomes.
Choice A (Experimental design) is not specific enough as there are various types of experimental designs. Choice B (Double-blind experiment) refers to a study where neither the participants nor the researchers know who is receiving the intervention, which is not the case here. Choice D (Repeated measures design) involves measuring the same participants at different time points, not separating them into different groups.
Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?
- A. A 65-year old male with urine output of 60cc in the past four hours
- B. A 2-month old female with a temperature of 100.6 rectally
- C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
- D. A 4-year old male with an oxygen saturation of 96% on room air
Correct Answer: D
Rationale: The correct answer is D because an oxygen saturation of 96% on room air indicates adequate oxygenation, suggesting the client is stable and can be discharged home. A: Low urine output may indicate dehydration or kidney issues, requiring further monitoring. B: A fever in an infant warrants evaluation for infection, not ready for discharge. C: Recent transition from IV TPN to full liquids may require ongoing monitoring for tolerance and nutritional status.
What question must the nurse ask when formulating a nursing diagnosis?
- A. What diagnosis did the physician make for this client?
- B. What is the issue that I can solve for this client?
- C. What physician orders will resolve this issue?
- D. What underlying disease does this client have?
Correct Answer: B
Rationale: The correct answer is B: What is the issue that I can solve for this client? When formulating a nursing diagnosis, the nurse should focus on identifying the client's actual or potential health problems that can be addressed through nursing interventions. This question helps the nurse to pinpoint the specific problem or need that requires nursing attention, leading to the development of an effective care plan.
A: Focusing on the physician's diagnosis is not relevant to formulating a nursing diagnosis.
C: Physician orders are important but not directly related to formulating a nursing diagnosis.
D: Identifying the underlying disease is important but not the primary focus when formulating a nursing diagnosis.
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
- A. The adolescent gives away a DVD player and a cherished autographed picture of a performer.
- B. The adolescent runs out of group therapy, swearing at the group leader, and then goes to her room.
- C. The adolescent becomes angry while speaking on the phone and slams down the receiver.
- D. The adolescent gets angry with her roommate when the roommate borrows her clothes without asking.
Correct Answer: A
Rationale: The correct answer is A because giving away cherished possessions can be a sign of preparing for suicide. This behavior may indicate a lack of concern for material possessions due to a belief that they won't be needed in the future. Choice B shows anger and isolation, not necessarily suicidal ideation. Choice C demonstrates anger but no indication of suicidal thoughts. Choice D shows anger towards the roommate, not self-harm intentions.
Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?
- A. The approximate length of the surgery
- B. The type of anticoagulants that will be prescribed
- C. The time of the next meal of solid food
- D. The length of time until the client can return to work
Correct Answer: A
Rationale: The correct answer is A: The approximate length of the surgery. This is the priority topic to instruct the client on admission because knowing the duration of the surgery helps manage the client's expectations and anxiety levels. Understanding the length of the procedure also allows the client to plan for post-operative care and recovery.
Choice B: The type of anticoagulants is important but not as critical on admission as knowing the surgery duration. Choice C: The time of the next meal is important for preoperative fasting but not as crucial as understanding the surgery length. Choice D: The length of time until the client can return to work is important, but it is a secondary concern compared to the immediate surgical procedure.