Nokea
In the early postoperative period, what is the priority concern for Mr. L, who has a tracheostomy and partial laryngectomy?
- A. Possible infection related to chemotherapy and surgical procedure
- B. Poor nutritional intake related to dysphagia and malignancy
- C. Difficulty communicating needs because of the tracheostomy tube
- D. High risk for aspiration because of secretions and removal of epiglottis
Correct Answer: D
Rationale: The correct answer is D: High risk for aspiration because of secretions and removal of epiglottis. This is the priority concern for Mr. L due to the risk of food or liquid entering the airway, leading to aspiration pneumonia and respiratory distress. The tracheostomy and partial laryngectomy compromise the airway protection mechanism, increasing the risk of aspiration. Options A and B are not the priority as infection and poor nutrition can be managed after addressing the risk of aspiration. Option C, while important for communication, is not as immediately life-threatening as the risk of aspiration.
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Mr. U (pulmonary resection) has developed a tension pneumothorax. He is currently receiving high-flow oxygen via nonrebreather mask but continues to experience respiratory distress. What is the priority action?
- A. Remove the occlusive dressing around the chest wound.
- B. Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
- C. Initiate cardiopulmonary resuscitation (CPR).
- D. Call for the crash cart and intubation equipment.
Correct Answer: B
Rationale: The correct answer is B: Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
Rationale:
1. Tension pneumothorax is a life-threatening emergency where air accumulates in the pleural space, causing lung collapse and increased pressure in the chest.
2. The standard treatment for tension pneumothorax is needle thoracostomy, which involves inserting a large-bore needle into the chest to release the trapped air.
3. In this scenario, Mr. U is in respiratory distress despite receiving high-flow oxygen, indicating a significant problem with ventilation that requires immediate intervention.
4. Performing a needle thoracotomy will rapidly decompress the tension pneumothorax, relieving pressure on the heart and lungs, and improving respiratory function.
5. This action takes precedence over other options such as removing the occlusive dressing, initiating CPR, or calling for intubation equipment, as immediate decompression is crucial in managing tension pneumoth
The community health nurse is listening to a client talk about a personal problem. Which of these actions by the nurse is most appropriate?
- A. The nurse should increase the physical distance from the client.
- B. The nurse should lean toward the client and make eye contact.
- C. The nurse should periodically interrupt the client to ask questions.
- D. The nurse should initiate the physical assessment to distract the client.
Correct Answer: B
Rationale: The correct answer is B because leaning towards the client and making eye contact demonstrates active listening and empathy, helping to build rapport and trust. This non-verbal communication shows the client that the nurse is engaged and attentive, creating a safe space for them to share their personal problem. Increasing physical distance (A) may convey disinterest or lack of connection. Periodically interrupting the client (C) can disrupt the flow of conversation and hinder the client's ability to express themselves. Initiating a physical assessment (D) would be inappropriate as it could feel intrusive and insensitive given the context of the client discussing a personal problem. Overall, choice B fosters a supportive environment for effective communication and client-centered care.
A hospital nurse is concerned about the demands of providing safe care to clients who are seriously ill. The nurse manager should suggest which intervention to effectively help the nurse balance the demanding work in the hospital setting?
- A. Delegate more tasks to the unlicensed nursing personnel on the unit.
- B. Request a transfer to another nursing care unit with patients who are stable.
- C. Write down stories in a journal about how caring makes a difference for patients.
- D. Use an assertive communication style for every patient3nurse interaction.
Correct Answer: B
Rationale: The correct answer is B: Request a transfer to another nursing care unit with patients who are stable.
Rationale:
1. By transferring to a unit with stable patients, the nurse can reduce the demands of caring for seriously ill clients.
2. This intervention helps in balancing the workload and provides a less stressful environment for the nurse.
3. It allows the nurse to focus on providing safe care without being overwhelmed by the demands of seriously ill patients.
Incorrect choices:
A: Delegating more tasks to unlicensed nursing personnel may not address the root cause of the nurse's concern and could potentially compromise patient safety.
C: Writing stories in a journal may be a helpful coping mechanism but does not directly address the nurse's workload concerns.
D: Using an assertive communication style is important but may not be the most effective solution for balancing the demands of caring for seriously ill clients.
The nurse manager asks the staff nurse to work an extra shift. Which response by the staff nurse is assertive and based on rational beliefs?
- A. "I don't want you upset, so I will work extra."
- B. "Why do I always have to cover extra shifts?"
- C. "I am not able to work an extra shift."
- D. "If you can't find anyone else, I will do it."
Correct Answer: C
Rationale: The correct answer is C because it directly and assertively communicates the staff nurse's inability to work an extra shift. This response sets clear boundaries and respects the nurse's own limitations and well-being. It is based on rational beliefs as it acknowledges personal capacity without guilt or unnecessary explanations.
Explanation of other choices:
A: This choice is not assertive as it prioritizes avoiding upsetting the nurse manager over the nurse's own needs and boundaries.
B: This response is confrontational and does not address the request directly, focusing instead on questioning past occurrences.
D: While this response offers to work the extra shift as a last resort, it does not assert the nurse's own limitations clearly, leaving room for potential guilt or manipulation.
The nurse cares for an adult client diagnosed with type 1 diabetes mellitus. Which is essential in building mutuality in the nurse3 client relationship?
- A. The nurse controls the relationship by retaining the power to make judgments about diabetes education.
- B. The nurse teaches diabetes management by involving the client in making decisions about self care.
- C. The nurse has expert knowledge of diabetes and formulates appropriate learning outcomes for the client.
- D. The nurse demonstrates trust and respect by solving problems for the client when issues occur with self-management.
Correct Answer: B
Rationale: The correct answer is B because it promotes mutual respect and collaboration in the nurse-client relationship. By involving the client in decision-making about self-care, the nurse empowers the client to take ownership of their health and fosters a sense of partnership. This approach enhances the client's autonomy and self-efficacy, leading to better adherence to the diabetes management plan.
Choice A is incorrect as it implies a power dynamic where the nurse controls the relationship, which can hinder trust and collaboration. Choice C is incorrect because while expert knowledge is valuable, it does not necessarily build mutuality unless shared in a collaborative manner. Choice D is incorrect as solving problems for the client may undermine their ability to develop problem-solving skills and independence in managing their condition.