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A nurse is a member of an interdisciplinary teamthat uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
- A. Add this data to the problem list.
- B. Focus chart using the DAR format.
- C. Document the variance in the patient’s record.
- D. Report a positive variance in the next interdisciplinary team meeting.
Correct Answer: C
Rationale: The correct answer is C: Document the variance in the patient’s record. By documenting the variance in the patient's record, the nurse can provide a clear record of the deviation from the critical pathway. This documentation is essential for tracking the patient's progress accurately and identifying potential issues that may require intervention. It allows for proper communication among the interdisciplinary team and ensures that everyone is aware of the deviation.
Choice A is incorrect because adding data to the problem list may not provide a comprehensive record of the variance. Choice B is incorrect because focusing on charting using the DAR format does not address the deviation from the critical pathway. Choice D is incorrect because reporting a positive variance in the next team meeting may not accurately reflect the patient's actual progress and may lead to miscommunication within the team.
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Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
- A. Ask the patient to repeat what was said in order to evaluate understanding.
- B. Stand directly in front of the patient to facilitate lip reading.
- C. Reduce environmental noise and distractions before communicating.
- D. Raise the voice to project sound at a higher frequency.
Correct Answer: C
Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication.
The other choices are incorrect because:
A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication.
B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication.
D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.
A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care?
- A. The increase in cultural diversity in the United States
- B. Staffing shortages in health care and questions concerning quality of care
- C. Increased costs of health care coupled with inequalities in access
- D. Ability of technology to prolong life beyond meaningful quality of life
Correct Answer: D
Rationale: The correct answer is D: Ability of technology to prolong life beyond meaningful quality of life. In palliative care, the focus is on improving the quality of life for patients with serious illnesses. The use of technology to prolong life can sometimes conflict with this goal, leading to ethical dilemmas. Technology may extend life without considering the patient's comfort or dignity, raising questions about the meaningfulness of prolonging life in such situations. This issue is particularly challenging in palliative care as it requires balancing the benefits of technology with the patient's quality of life.
Other choices are incorrect:
A: The increase in cultural diversity in the United States - While cultural diversity can present challenges in palliative care, it is not the most often presented challenging ethical issue.
B: Staffing shortages in health care and questions concerning quality of care - Staffing shortages are important issues in healthcare, but they do not directly relate to the ethical dilemmas specific to palliative care.
C: Increased costs of health care coupled with
A nurse has provided care to a patient. Whichentry should the nurse document in the patient’s record?
- A. Status unchanged, doing well
- B. Patient seems to be in pain and states, “I feel uncomfortable.”
- C. Left knee incision 1 inch in length without redness, drainage, or edema
- D. Patient is hard to care for and refuses all treatments and medications. Family is present.
Correct Answer: C
Rationale: The correct answer is C because it provides specific, objective information about the patient's left knee incision, including its size and absence of concerning signs. This entry is relevant, concise, and focuses on a specific aspect of the patient's condition, aiding in continuity of care and treatment planning.
Choice A is vague and lacks detail, making it insufficient for accurate patient care documentation. Choice B focuses on the patient's subjective feelings and does not provide objective assessment data. Choice D is judgmental and includes unnecessary information about the patient's behavior and family presence, which is not directly related to the patient's condition.
A 66-year-old patient is in a hospice receiving palliative care for lung cancer which has metastasized to the patients liver and bones. For the past several hours, the patient has been experiencing dyspnea. What nursing action is most appropriate to help to relive the dyspnea the patient is experiencing?
- A. Administer a bolus of normal saline, as ordered.
- B. Initiate high-flow oxygen therapy.
- C. Administer high doses of opioids.
- D. Administer bronchodilators and corticosteroids, as ordered.
Correct Answer: B
Rationale: The correct answer is B: Initiate high-flow oxygen therapy. Dyspnea in a patient with lung cancer can be caused by hypoxia due to compromised lung function. High-flow oxygen therapy can help improve oxygenation and alleviate dyspnea. Administering a bolus of normal saline (A) would not directly address the underlying cause of dyspnea. Administering high doses of opioids (C) may lead to respiratory depression and should be used cautiously in patients experiencing dyspnea. Administering bronchodilators and corticosteroids (D) may be appropriate for certain types of dyspnea, but in this case, addressing hypoxia with high-flow oxygen therapy is the most appropriate initial nursing action.
A nurse is inserting an indwelling urinary catheterfor a male patient. Which action will the nurse take?
- A. Hold the shaft of the penis at a 60-degree angle.
- B. Hold the shaft of the penis with the dominant hand.
- C. Cleanse the meatus 3 times with the same cotton ball from clean to dirty.
- D. Cleanse the meatus with circular strokes beginning at the meatus and working outward.
Correct Answer: D
Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.