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1. A client with Crohn's disease is receiving parenteral nutrition. Which of the following interventions should the nurse not include in the care of this client?
- A. Remove the parenteral nutrition solution from the refrigerator 2 hours before infusion.
- B. Remove unused parenteral nutrition after 12 hours of use.
- C. Monitor daily laboratory values and report abnormalities as needed.
- D. Monitor the flow rate of the parenteral nutrition carefully and adjust it if necessary.
Correct answer: B
Rationale: In caring for a client receiving parenteral nutrition, it is important to follow proper guidelines to ensure safety and effectiveness. Unused parenteral nutrition should be removed after 24 hours, not 12 hours, to prevent contamination and reduce the risk of infection. Option A is correct as it ensures the solution is at room temperature before infusion. Option C is essential for monitoring the client's response to parenteral nutrition. Option D is important to maintain the correct flow rate and adjust it as needed. Therefore, option B is the incorrect choice among the options provided.
2. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is
- A. professional course towards credits
- B. inservice education
- C. advance training
- D. continuing education
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
3. You are doing bed bath to the client when suddenly, The nursing assistant rushed to the room and tell you that the client from the other room was in Pain. The best intervention in such case is:
- A. Raise the side rails, cover the client and put the call bell within reach and then attend to the client in pain to give the
- B. Tell the nursing assistant to give the pain medication to the client complaining of pain
- C. Tell the nursing assistant to go the client’s room and tell the client to wait
- D. Finish the bed bath quickly then rush to the client in Pain
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
4. What is the primary function of a written nursing care plan?
- A. Evaluates whether nursing care goals have been achieved
- B. Ensures the provision of quality nursing care
- C. Assists in selecting the appropriate nursing interventions
- D. Facilitates the creation of a nursing diagnosis
Correct answer: D
Rationale: A written nursing care plan fundamentally serves to facilitate the development of a nursing diagnosis. This procedure involves analyzing patient data and identifying health problems that nurses can address independently. This analysis then aids in determining the most appropriate nursing interventions for the identified health issues. Although evaluating the achievement of nursing care goals is an important aspect, it is not the primary function of a nursing care plan. Similarly, while delivering quality nursing care is crucial, it is a broader concept that includes many other facets beyond just the initial nursing diagnosis and interventions.
5. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:
- A. Percussion uses only one hand, while vibration uses both hands
- B. Percussion delivers cushioned blows to the chest with cupped palms, while vibration gently shakes secretions loose
- C. In both percussion and vibration, the hands are not on top of each other, and hand action is not in tune with the client's breath
- D. Percussion slaps the chest to loosen secretions, while vibration shakes the secretions along with the inhalation
Correct answer: D
Rationale: Chest percussion involves the use of rhythmic tapping to dislodge mucus from the lungs, facilitating its movement toward the larger airways where it can be expelled. This technique is particularly important in conditions where mucus retention is a significant risk factor for infection. The key difference between chest percussion and vibration is that percussion involves slapping the chest to loosen secretions, while vibration involves shaking the secretions along with the inhalation, aiding in moving the loosened secretions upwards for easier removal. Choices A, B, and C do not accurately describe the main difference between chest percussion and vibration, making them incorrect.
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