Which of the following statement is NOT true about standards of care?

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Question 1 of 9

Which of the following statement is NOT true about standards of care?

Correct Answer: C

Rationale: Standards guide practice (A), are evidence-based (B), ensure quality (D) 'vary by nurse' (C) isn't true, uniform, per regulation. C's variation contradicts consistency for Mr. Gary's care, making it untrue.

Question 2 of 9

The nurse is assessing a post operative client who underwent a colostomy, which of the following findings will warrant further nursing interventions?

Correct Answer: A

Rationale: A pale, dry stoma e.g., ischemia needs intervention (e.g., notify MD), unlike red (healthy), bloody-to-green (normal), or green (expected). Nurses assess e.g., color for complications, per ostomy care.

Question 3 of 9

The nurse is caring for clients in a rural health clinic and wants to promote illness prevention. Which action should the nurse take?

Correct Answer: A

Rationale: In a rural clinic, illness prevention primary prevention aims to stop disease before it starts, critical where access lags. Providing accident prevention education, like safe tractor use or fall risks, targets common rural hazards, reducing injuries proactively. Screening for hypertension is secondary, detecting issues, not preventing them. Referring chronic cases to specialists or teaching diabetic diets is tertiary, managing existing conditions, not averting onset. Accident prevention fits rural needs data shows higher injury rates in such areas empowering clients with knowledge to avoid harm. The nurse's action aligns with nursing's preventive role, addressing environmental and lifestyle risks unique to the setting, enhancing community health by tackling root causes before they escalate, a practical step given limited rural resources.

Question 4 of 9

Which of the following statement is NOT true about safety protocols?

Correct Answer: C

Rationale: Safety protocols reduce harm (A), guide care (B), are nursing (D) 'only for emergencies' (C) isn't true, used always, per standards. C's limit contradicts broad use, like Mr. Gary's routine care, making it untrue.

Question 5 of 9

Caring is healing, it is communicated through the consciousness of the nurse to the individual being cared for. It allows access to higher human spirit.

Correct Answer: B

Rationale: Jean Watson's Human Caring Theory, developed in the 1970s, defines caring as a healing force transmitted through the nurse's consciousness, connecting to the patient's spirit. She sees nursing as transcending physical acts, fostering openness to a higher human essence. Unlike Benner's skill progression, Leininger's cultural focus, or Swanson's process model, Watson's approach is deeply philosophical, emphasizing transpersonal caring moments like a nurse's empathy soothing a dying patient's fear. Her 10 Carative Factors (e.g., instilling hope) guide this spiritual exchange, influencing holistic nursing practices globally, particularly in palliative care, where emotional and existential support is paramount.

Question 6 of 9

A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?

Correct Answer: A

Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.

Question 7 of 9

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?

Correct Answer: A

Rationale: A high-pressure alarm on a ventilator indicates obstruction or resistance, often from secretions; suctioning (A) is the priority to clear the airway. Checking for disconnection (B) fits low-pressure alarms. Notifying respiratory therapy (C) delays action. Evaluating the cuff (D) addresses leaks, not high pressure. A is correct. Rationale: Suctioning resolves common causes like mucus plugs, restoring ventilation swiftly, a first-line action per ventilator management protocols, critical to prevent hypoxia or barotrauma.

Question 8 of 9

A client has a new prescription for a low-fat diet. Which of the following foods should be recommended?

Correct Answer: C

Rationale: When following a low-fat diet, it is essential to choose foods that are low in fat. Chicken breast is a lean protein source that is low in fat, making it a suitable option for a low-fat diet. Bacon, whole milk, and cheese are higher in fat content and should be avoided or limited in a low-fat diet. Bacon is high in saturated fat, whole milk contains significant amounts of fat, including saturated fat, and cheese is also high in fat. Therefore, these options are not ideal for a low-fat diet.

Question 9 of 9

Mr. Gary is a 67 year old client who is experiencing chronic pain. Which of the following is the best way to assess his pain?

Correct Answer: D

Rationale: For Mr. Gary's chronic pain at 67, a standardized pain scale (D) best assesses intensity, per pain management standards (e.g., numeric scale). Observation (A) misses subjectivity, description (B) lacks precision, physical assessment (C) is secondary. Scales quantify chronic pain reliably, especially in older adults, making D the optimal choice.

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