What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?

Correct Answer: A

Rationale: Monitoring I&O ensures fluid balance with hyperosmotic enteral feeding.

Correct Answer: C

Rationale: Cultural competence respects beliefs (A), improves care (B), enhances communication (D) 'impose her beliefs' (C) isn't true, as it contradicts respecting client culture, per standards. C's imposition opposes competence's goal of sensitivity, making it the untrue statement.

Correct Answer: D

Rationale: Total patient care excels with many nurses and few patients, allowing each nurse to fully address one client's needs e.g., bathing, meds, education. Functional nursing assigns tasks (e.g., one nurse for vitals), team nursing divides labor, and primary nursing focuses continuity, but ample staffing makes total care ideal. For instance, a nurse can devote time to a single ICU patient, optimizing outcomes. This model leverages resources for intensive, individualized attention, enhancing care quality in such scenarios.

Correct Answer: A

Rationale: Quadriplegia isn't an oral temp contraindication e.g., a paralyzed patient can hold a thermometer if alert. NGT (obstruction), dyspnea (breathing), and nausea (gagging) preclude it. Nurses opt for alternatives e.g., axillary per safety protocols.

Correct Answer: C

Rationale: Heart surgery in a specialized hospital is tertiary care (C) advanced, per system. Primary (A) initial, secondary (B) referral, promotion (D) preventive not surgical. C fits high-level care, making it correct.

Correct Answer: D

Rationale: NANDA defines acute pain as lasting up to 6 months, beyond which it's chronic. Nurses use this timeframe for diagnosis accuracy.

Correct Answer: D

Rationale: Cupped hands during chest percussion loosen mucus in cystic fibrosis, creating vibrations without pain, a key physiotherapy technique to clear airways. Heel strikes are harsh, frequent repositioning isn't routine, and post-meal percussion risks reflux. Nurses teach this method for effective secretion management, improving breathing and reducing infection risk in this chronic condition.

Correct Answer: B

Rationale: Adult bladder capacity is 400-500 ml e.g., typical urge at 300-400. Less (50-200) or more (800-1000) don't fit. Nurses note e.g., catheter output for function, per physiology.

Correct Answer: A

Rationale: Sims left lateral allows easy access to the rectum and comfort during an enema.