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1. Which of the following is an example of a secondary prevention activity?
- A. Blood pressure screening
- B. Administering medications
- C. Developing a care plan
- D. Providing rehabilitation
Correct answer: A
Rationale: The correct answer is A, blood pressure screening. Secondary prevention aims to identify and treat conditions early to prevent their progression. Blood pressure screening helps in early detection of hypertension, allowing for timely intervention. Choices B, C, and D are not examples of secondary prevention activities. Administering medications (B) can be part of treatment after a condition is diagnosed, developing a care plan (C) is more related to organizing and coordinating care rather than prevention, and providing rehabilitation (D) focuses on recovery and improvement post-diagnosis rather than early detection and prevention.
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.
- A. When a heart ceases to beat, the client is pronounced clinically dead.
- B. Physicians must write do not resuscitate (DNR) orders.
- C. A DNR order can be written after the health-care provider has discussed it with the client and family.
- D. A DNR requires a court decision.
Correct answer: C
Rationale: A DNR order can be written after the health-care provider has discussed it with the client and family.
4. What is the role of the Joint Commission in healthcare?
- A. Advocacy for patients
- B. Setting standards for patient care
- C. Providing direct patient care
- D. Approving healthcare facilities
Correct answer: D
Rationale: The correct answer is D: 'Approving healthcare facilities.' The Joint Commission's primary role is to accredit and certify healthcare organizations and programs in the United States. This accreditation ensures that healthcare facilities meet specific quality and safety standards. Choices A, B, and C are incorrect because the Joint Commission focuses on evaluating and accrediting healthcare facilities rather than advocating for patients, providing direct care, or setting standards for patient care.
5. A nurse is evaluating teaching for a client who has heart failure. Which of the following statements by the client indicates an understanding of the teaching?
- A. I am limiting my sodium intake to 2 grams daily.
- B. I have been weighing myself every other morning.
- C. I am trying to decrease my intake of foods with potassium.
- D. I am eating fewer potato chips and more fruit for snacks.
Correct answer: A
Rationale: The correct answer is A. Limiting sodium intake is crucial for clients with heart failure to manage their condition effectively. Excessive sodium can lead to fluid retention and worsen heart failure symptoms. Weighing oneself is important for monitoring fluid retention but does not directly show an understanding of dietary restrictions. Decreasing potassium intake is not typically recommended for heart failure clients unless specifically advised by a healthcare provider. While choosing healthier snacks is beneficial, the focus on sodium intake is more critical for heart failure management.
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