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You highly suspect that your assigned client has abdominal distention. You most need to do and chart which of the following things?
- A. Have another nurse verify your suspicions.
- B. Measure the abdominal girth at the umbilicus.
- C. Measure abdominal girth at the most distended level.
- D. Ask the client if they are distended.
Correct Answer: C
Rationale: Measuring girth at the most distended level and charting it confirms abdominal distention objectively, critical for tracking. Verification, umbilicus measurement, or client query are less precise. Nurses rely on this for accurate monitoring.
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The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?
- A. Arranging for the wheelchair
- B. Asking her family to visit
- C. Assisting her to sit out of bed in a chair qid
- D. Encouraging the use of an overhead trapeze
Correct Answer: D
Rationale: The trapeze promotes upper body strength and mobility, aiding recovery.
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
One tablet of chlorine is efficient to chlorinate how many litres of water?
- A. 10 Litres
- B. 20 Litres
- C. 30 Litres
- D. 40 Litres
Correct Answer: B
Rationale: Chlorine tablets disinfect water by releasing hypochlorous acid to kill pathogens. Standard tablets (e.g., 1 mg chlorine) are designed to treat specific volumes based on concentration needs (typically 0.5-2 mg/L). Choice A (10 L) underestimates common tablet capacity, while C (30 L) and D (40 L) exceed typical single-tablet efficacy without specifying tablet strength. B (20 L) aligns with widely used chlorine tablets (e.g., NaDCC) for household water purification, achieving safe levels per WHO guidelines. Nurses educating communities on water safety must clarify dosage, ensuring effective pathogen control without overdose, making 20 L the correct, practical answer.
Health is a state of complete physical, mental and social well-being not merely the absence of disease or infirmity;
- A. World Diabetes Federation (WDF)
- B. International Council of Nursing (ICN)
- C. American Nurses Association (ANA)
- D. World Health Organization(WHO)
Correct Answer: D
Rationale: The World Health Organization (WHO) defines health as 'complete physical, mental, and social well-being, not merely the absence of disease,' established in 1948. This holistic view shapes global health policy and nursing e.g., addressing mental health alongside infections. The World Diabetes Federation focuses on diabetes, not broad definitions. The International Council of Nurses supports practice standards, not health definitions. The American Nurses Association governs U.S. nursing, adopting WHO's view, not originating it. WHO's authoritative, universal definition drives health promotion, making it the source here.
One of the primary reasons for conducting nursing research is to:
- A. Decrease costs associated with client care
- B. Generate knowledge to guide practice
- C. Allow nurses to delegate more tasks
- D. Assist physicians in their research
Correct Answer: B
Rationale: Nursing research's primary aim is to generate knowledge to guide practice, building a scientific foundation that informs and improves care delivery. This involves studying interventions like pain management techniques or outcomes, like recovery rates, to create evidence-based guidelines that enhance safety and effectiveness. Decreasing costs, while a potential byproduct, isn't the core focus; research prioritizes quality over economics. Delegating tasks relates to workflow, not research goals, and assisting physicians, though collaborative, isn't nursing's aim its focus is autonomous advancement. This knowledge generation refines assessment, planning, and intervention, ensuring nurses address client needs with precision. For example, research on pressure ulcer prevention shapes protocols, directly impacting practice. This purpose elevates nursing as a science-driven profession, distinct from mere support roles, fostering innovation and accountability in healthcare.