Nokea
Which term describes a nurse’s inability to differentiate between the beliefs of clients in the same culture?
- A. Generalization
- B. Stereotyping
- C. Ethnocentrism
- D. Cultural imposition
Correct Answer: B
Rationale: Stereotyping involves oversimplifying and applying generalized beliefs to individuals within a culture, hindering effective care.
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What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU?
- A. Monitoring arterial blood gases
- B. Electrocardiographic (ECG) monitoring
- C. Determining fluid and electrolyte status
- D. Direct arterial blood pressure monitoring
Correct Answer: B
Rationale: ECG monitoring assesses cardiovascular function, detecting arrhythmias or ischemia.
The third stage of labor is when:
- A. Contractions reach their peak
- B. The head is visible
- C. The water breaks
- D. The placenta is delivered
Correct Answer: D
Rationale: The third stage of labor involves the delivery of the placenta after the baby is born.
A postoperative priority nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. activity intolerance.
- B. ineffective airway clearance.
- C. high-risk for infection.
- D. an altered oral mucous membrane.
Correct Answer: B
Rationale: The laryngectomy client should be able to gradually increase activities without difficulty. The laryngectomy client may have copious amounts of secretions, which will require suctioning for the first 24-48 hours. Because the mucous collects in the cannula, it will require cleaning after the first 24 hours. Even though the client does have a potential for infection, this is not more important than the ineffective airway clearance. An altered mucous membrane problem is not more important than ineffective airway clearance. The client's mouth may become dry, but can be taken care of with good oral care.
The charge nurse assigned the care of a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegate to the nursing assistant? (Choose all that apply.)
- A. Provide oral care every 3-4 hours
- B. Monitor for indications of dehydration
- C. Administer 0.45% saline by IV line
- D. Assess daily weights for trends
Correct Answer: A
Rationale: Oral care and assessing daily weights are tasks that can be delegated to a nursing assistant. Monitoring for dehydration and administering IV fluids require more advanced clinical skills.
Which of the following tasks is most appropriate to delegate to the nursing assistant?
- A. Escort the family to a place of privacy
- B. Go with the organ donor specialist to talk to the family
- C. Assist with postmortem care
- D. Assist the family to collect belongings
Correct Answer: C
Rationale: Postmortem care involves basic hygiene and positioning, which can be performed by a nursing assistant.