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1. When a client who is in pain refuses to be repositioned, what should the nurse consider first in making a decision about what to do?
- A. Why a decision is needed.
- B. Who actually gets to make the decision?
- C. What are the alternatives?
- D. When a decision is needed.
Correct answer: A
Rationale: In this scenario, the nurse should first consider why a decision is needed. Understanding the underlying reason for the decision helps in selecting the best action to meet the desired goal. Who actually makes the decision is important but not the primary consideration. Exploring alternatives comes after determining the reason for the decision, who makes it, and when it is needed.
2. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
- A. Hydrocolloid
- B. Transparent
- C. Gauze
- D. Alginate
Correct answer: A
Rationale: The correct answer is A: Hydrocolloid. For a stage 2 pressure injury, a hydrocolloid dressing is recommended. Hydrocolloid dressings provide a moist environment that promotes healing and is effective for wounds with moderate exudate. Choice B (Transparent) is not typically used for stage 2 pressure injuries as it is more suitable for superficial wounds. Choice C (Gauze) is not ideal for stage 2 pressure injuries as it can adhere to the wound bed and cause trauma upon removal. Choice D (Alginate) is more appropriate for wounds with heavy exudate, not typically seen in stage 2 pressure injuries.
3. As the definition of nursing evolved, which of the following nurse theorists focused on the uniqueness of nursing?
- A. Florence Nightingale
- B. Virginia Henderson
- C. Martha Rogers
- D. Abraham Maslow
Correct answer: B
Rationale: Virginia Henderson�s definition of nursing focused on its uniqueness.
4. While interviewing for a position at City Hospital, the nurse asks about the organizational structure of the institution. She is told that the hospital is organized into departments based on specialty (e.g., nursing, dietary, pharmacy, etc.). Based on what you know about organizational structure, select the structure in this example.
- A. Parallel
- B. Functional
- C. Service-integrated
- D. Matrix
Correct answer: B
Rationale: The correct answer is 'Functional.' In a functional structure, organizations group employees into departments based on specialty, where similar tasks are performed by the same group. In this scenario, the hospital organizing its departments by specialty such as nursing, dietary, and pharmacy aligns with the characteristics of a functional structure. Choice A, 'Parallel,' does not fit the scenario described; parallel structures involve separate, independent units operating in parallel with little interaction. Choice C, 'Service-integrated,' does not align with the scenario either as it involves integrating services across departments. Choice D, 'Matrix,' is not the correct answer as it involves a complex organizational structure where employees report to multiple managers simultaneously, which is not the case in the scenario provided.
5. When planning care for a client with vision loss, which of the following interventions should the nurse include in the plan of care to assist the client with feeding?
- A. Arrange food in a consistent pattern on the client's plate
- B. Thicken liquids on the client's tray
- C. Provide small-handled utensils for the client
- D. Assign a staff member to feed the client
Correct answer: A
Rationale: When a client has vision loss, arranging food in a consistent pattern on the plate can help them locate and identify different food items more easily. This intervention promotes independence and allows the client to feed themselves with greater ease. Thicking liquids on the tray, providing small-handled utensils, or assigning a staff member to feed the client may not directly address the client's need for assistance with feeding due to vision loss. Thicking liquids is more related to swallowing difficulties, providing small-handled utensils can be helpful for clients with limited dexterity, and assigning a staff member to feed the client may not promote independence.
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