Nokea
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
- A. Ensured the client's safety which is a high patient care priority
- B. Violated Respondeat Superior
- C. Violated the client's right to dignity
- D. Committed a crime
Correct Answer: A
Rationale: Using a bed sheet for safety does not constitute a violation or crime.
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A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
- A. Substance abuse
- B. Substance intoxication
- C. Substance dependence
- D. Recreational use of a social drug
Correct Answer: C
Rationale: The correct answer is C: Substance dependence. This scenario describes a pattern of symptoms indicative of substance dependence, which includes tolerance, withdrawal symptoms when trying to cut back, unsuccessful attempts to quit, and continued use despite negative consequences. The patient's reliance on cigarettes to manage anxiety, craving, poor concentration, and headache indicates a psychological and physical dependence on nicotine.
A: Substance abuse typically involves harmful use of a substance but does not necessarily include physiological dependence.
B: Substance intoxication refers to the immediate effects of a substance in the body, not the long-term pattern of dependence.
D: Recreational use of a social drug implies occasional and non-regular use, which does not align with the described scenario of chronic, daily smoking leading to withdrawal symptoms.
How many drops per minute would you administer when the doctor's order states that the client should receive 1 liter of fluid over 8 hours and the intravenous set delivers 20 gtts per cc?
- A. 31 gtts
- B. 42 gtts
- C. 48 gtts
- D. 51 gtts
Correct Answer: A
Rationale: 1 L = 1000 mL; 1000 mL / 8 hr = 125 mL/hr; 125 mL x 20 gtts/mL / 60 min = 31.25 gtts/min, rounded to 31 (A).
The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration?
- A. The American Nurses Association's Scopes of Practice
- B. The American Nurses Association's Standards of Care
- C. State statutes
- D. Federal law
Correct Answer: C
Rationale: State statutes define the legal scope of practice for nurses and other healthcare personnel.
Which of the following health care system barriers can affect a patient's adherence?
- A. Treatment of asymptomatic disease
- B. Inadequate follow-up or discharge planning
- C. Forgetfulness
- D. Inadequate health insurance
Correct Answer: B
Rationale: Inadequate follow-up or discharge planning disrupts continuity of care, a systemic barrier to adherence.
You are caring for a client who has been taking illicit amphetamines and states that they continue to use this illicit drug because they 'suffer and feel lousy' when they try to stop taking it. Which nursing diagnosis is the most appropriate for this client?
- A. Psychological dependence secondary to amphetamine use
- B. Substance abuse secondary to amphetamine use
- C. Addiction secondary to amphetamine use
- D. Physical dependence secondary to amphetamine use
Correct Answer: D
Rationale: Physical dependence (D) is indicated by withdrawal symptoms.