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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. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrists before applying the restraints.
- B. Evaluate the client's circulation every 8 hours after application.
- C. Secure the restraint ties to the bed's side rails.
- D. Remove the restraints every 4 hours to evaluate the client's status.
Correct answer: C
Rationale: When applying wrist restraints, it is crucial to secure the restraint ties to the bed's side rails to ensure the client's safety and prevent injury. Padding the client's wrists (Choice A) is not a standard practice and may compromise the effectiveness of the restraints. Evaluating the client's circulation (Choice B) is important but should be done more frequently than every 8 hours to ensure prompt detection of any circulation issues. Removing the restraints every 4 hours (Choice D) is unnecessary and may increase the risk of injury or agitation in the client.
3. Which of the following is a potential benefit of social media?
- A. Sharing the fun side of nursing by posting a video of nurses singing and dancing in the hallways of the hospital while on duty
- B. Connecting with clients to keep up with their health status
- C. Connecting with the public to encourage healthy behaviors
- D. Sharing pictures of interesting clinical experiences with friends
Correct answer: C
Rationale: The correct answer is C because connecting with the public to encourage healthy behaviors is a significant benefit of social media. It allows for the dissemination of valuable health information, promoting healthy habits, and raising awareness about important health issues. Choices A, B, and D are not as impactful as choice C in terms of promoting public health and healthy behaviors. Choice A focuses more on entertainment rather than health promotion, choice B is specific to client connections rather than public health initiatives, and choice D is more about sharing experiences rather than encouraging healthy behaviors.
4. What is dysfunctional turnover?
- A. Retaining all employees.
- B. Losing employees consistently.
- C. Losing highly skilled employees who are hard to replace.
- D. Hiring new employees.
Correct answer: C
Rationale: Dysfunctional turnover refers to the loss of valuable, skilled employees who are challenging to replace. This turnover can be detrimental to an organization's performance and productivity. Choices A, B, and D are incorrect because dysfunctional turnover specifically involves losing high-quality employees, not retaining all employees, losing employees consistently, or hiring new employees.
5. A nurse recognizes which of the following as a primary goal of nursing?
- A. Assist patients to achieve a peaceful death.
- B. Improve personal knowledge and skills to enhance patient outcomes.
- C. Advocate for quality of life rather than quantity of life.
- D. Work to control costs to enhance patients' quality of life.
Correct answer: A
Rationale: The primary goal of nursing is to promote health, prevent illness, alleviate suffering, and care for the sick. Assisting patients to achieve a peaceful death is an essential aspect of nursing care, ensuring dignity and comfort in the end-of-life phase. While improving personal knowledge and advocating for quality of life are important aspects of nursing, the primary goal remains the well-being and comfort of patients, even in death. Working to control costs, while a consideration in healthcare, is not the primary goal of nursing, which is centered on patient care and well-being.
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