Nokea
A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy?
- A. Administer an antiemetic.
- B. Administer an antimetabolite.
- C. Administer a tumor antibiotic.
- D. Administer an anticoagulant.
Correct Answer: A
Rationale: Nausea and vomiting are common adverse effects of chemotherapy. Administering an antiemetic helps to prevent or reduce these symptoms in patients undergoing chemotherapy. By managing nausea and vomiting, the patient's overall well-being and quality of life during treatment can be improved. Therefore, providing an antiemetic medication is essential in combating these adverse effects and promoting patient comfort and compliance with treatment.
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A nurse is providing care to a group of patients.Which situation will require the nurse to obtain a telephone order?
- A. As the nurse and health care provider leave a patient’s room, the primary care provider gives the nurse an order.
- B. At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.
- C. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order.
- D. A nurse reads an order correctly as written by the health care provider in the patient’s medical record
Correct Answer: B
Rationale: In this situation, the nurse needs to obtain a telephone order because the patient's condition has changed significantly. The drop in blood pressure from 120/80 to 90/50 along with the saturated incision dressing indicates a potential complication or need for immediate intervention. The nurse must act quickly to address the situation and may require additional orders from the primary care provider over the phone to manage the patient's condition effectively. The urgency and critical nature of the situation necessitate obtaining a telephone order promptly to ensure the best outcome for the patient.
A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action?
- A. To promote autonomy
- B. To use common courtesy
- C. To establish trustworthiness
- D. To standardize communication
Correct Answer: D
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.
A nurse is explaining to the nursing students working on the antepartum unit how to assess for edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? N R I G B.C M U S N T O
- A. +1
- B. +2
- C. +3
- D. 4
Correct Answer: C
Rationale: Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as
+1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities
is +2 edema. Generalized massive edema (+4) includes the accumulation of fluid in the
peritoneal cavity.
The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first time. What is the most significant challenge experienced by a patient with hearing loss who is adapting to using a hearing aid for the first time?
- A. Regulating the tone and volume
- B. Learning to cope with amplification of background noise
- C. Constant irritation of the external auditory canal
- D. Challenges in keeping the hearing aid clean while minimizing exposure to moisture
Correct Answer: B
Rationale: One of the most significant challenges experienced by patients with hearing loss who are adapting to using a hearing aid for the first time is learning to cope with the amplification of background noise. When a person starts using a hearing aid after experiencing hearing loss, they may find that the device picks up not only the sounds they want to hear but also surrounding noises, such as background chatter, traffic noise, or ambient sounds. This sudden increase in volume and clarity of background noise can be overwhelming and challenging for the individual to adjust to. It can affect their ability to focus on conversations or specific sounds they are trying to hear, leading to frustration and potentially causing them to avoid using the hearing aid altogether. Supporting the patient in gradually acclimating to these new sounds and providing strategies for managing background noise can help improve their overall experience with the hearing aid.
To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select allthat apply.)
- A. Allows fasting on Yom Kippur for a Jewish patient
- B. Allows caffeine drinks for a Mormon patient
- C. Serves no ham products to a Muslim patient
- D. Serves kosher foods to a Christian patient
Correct Answer: A
Rationale: A. Allowing fasting on Yom Kippur for a Jewish patient demonstrates culturally sensitive care by respecting and accommodating the religious practices of the patient. Yom Kippur is an important day of fasting and repentance in the Jewish faith, and by allowing the patient to observe this practice, the nurse shows understanding and support.