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1. During a physical assessment of adult clients, which of the following techniques should the nurse use?
- A. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client experiencing pain.
- B. Palpate the client's abdomen before auscultating bowel sounds.
- C. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
- D. Obtain an apical heart rate by auscultating at the third intercostal space to the left of the sternum.
Correct answer: B
Rationale: When performing a physical assessment, it is essential to palpate the client's abdomen before auscultating bowel sounds. This sequence helps prevent altering bowel sound results due to the pressure applied during palpation. Choice A is incorrect because the FLACC pain rating scale is typically used for nonverbal or pediatric clients, not adults. Choice C is incorrect because the bladder of the blood pressure cuff should surround about 80% of the client's arm circumference, not the bladder of the cuff itself. Choice D is incorrect because to obtain an apical heart rate, auscultation should be done at the fifth intercostal space at the midclavicular line, not at the third intercostal space to the left of the sternum.
2. One of the steps in coaching is often overlooked and taken for granted. What is this step?
- A. Stating the target
- B. Jumping to conclusions
- C. Asking for suggestions
- D. Tying the problem to clients' care
Correct answer: D
Rationale: In coaching, tying the problem to clients' care is crucial but often overlooked. This step ensures that the coach and the client focus on issues directly impacting the client's well-being. Stating the target (choice A) is important but not as critical as tying the problem to clients' care. Jumping to conclusions (choice B) is counterproductive in coaching as it may lead to incorrect assumptions. Asking for suggestions (choice C) is valuable, but it does not address the core aspect of linking the issue to the client's care, which is essential for effective coaching.
3. Which of the following laws govern nursing practice?
- A. Statutory laws
- B. Common laws
- C. Administrative laws
- D. Constitutional laws
Correct answer: A
Rationale: Statutory laws govern nursing practice. These laws are enacted by legislative bodies and regulate various aspects of nursing practice, including licensure requirements, scope of practice, and patient care standards. Common laws, administrative laws, and constitutional laws may also impact nursing practice, but statutory laws specifically outline the legal framework for nursing professionals to follow. Common laws are based on court decisions and precedents, not specific to nursing practice. Administrative laws deal with regulations set by administrative agencies. Constitutional laws relate to the fundamental rights and principles outlined in the constitution, not specifically governing nursing practice.
4. An RN cared for a state senator during the day shift. Later that day he was having dinner with friends when the news mentioned the senator had been hospitalized. The RN’s friends asked if he knew what was wrong with the senator. Which ethical principle should the RN consider when replying?
- A. Fidelity
- B. Confidentiality
- C. Veracity
- D. Accountability
Correct answer: B
Rationale: The principle of confidentiality requires nurses to hold healthcare information and anything patients tell them in the strictest confidence.
5. In the traditional rating scale, what is the time period typically used for evaluation?
- A. Twelve months
- B. Six months
- C. Three months
- D. One month
Correct answer: A
Rationale: In the traditional rating scale, evaluations are typically conducted over a 12-month period. This duration allows for a comprehensive assessment of the employee's performance and progress throughout the year, capturing a broader range of experiences and accomplishments to provide a more holistic evaluation. Choices B, C, and D are incorrect because they do not align with the standard practice of conducting annual evaluations in a traditional rating scale setting.
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