Nokea
A client expresses concern about hair loss during chemotherapy. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy begins.
- B. Offer resources for wigs and head coverings.
- C. Assure the client that hair loss will be minimal.
- D. Ignore the client's concerns about hair loss.
Correct Answer: B
Rationale: During chemotherapy, hair loss is a common side effect. Offering resources for wigs and head coverings can help the client cope with this change in appearance, maintain self-esteem, and feel more comfortable during the process. Encouraging the client to cut their hair short does not address the emotional impact of hair loss and may not be the client's preference. Assuring the client that hair loss will be minimal may provide false hope as significant hair loss is a common occurrence. Ignoring the client's concerns is not appropriate and goes against the principles of providing holistic and compassionate care.
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The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?
- A. Do not change the mask if the nurse is comfortable.
- B. Change the mask when relieved by the next shift.
- C. Apply a new mask.
- D. Reapply the mask after it air-dries.
Correct Answer: C
Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.
A patient with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. What is the most appropriate action to improve the patient's oxygenation?
- A. Encourage the patient to use incentive spirometry.
- B. Administer oxygen via nasal cannula as prescribed.
- C. Assist the patient with coughing and deep breathing exercises.
- D. Position the patient in a high Fowler's position.
Correct Answer: B
Rationale: Administering oxygen via nasal cannula as prescribed is the most appropriate action to improve the patient's oxygenation in COPD. Oxygen therapy helps maintain adequate oxygen levels in the blood, which is crucial for managing COPD. Encouraging the use of incentive spirometry, assisting with coughing and deep breathing exercises, and positioning the patient in high Fowler's position are all beneficial interventions, but administering oxygen is the priority for immediate oxygenation support in COPD.
A nurse manager assigns a nursing assistant a task outside of their role. What should the nursing assistant do?
- A. Follow the manager's directive
- B. Report the task to the charge nurse
- C. Refuse to perform the task
- D. Perform the task and document later
Correct Answer: B
Rationale: If a nurse manager assigns a nursing assistant a task that is outside of their role, the nursing assistant should report the task to the charge nurse. This is important because the charge nurse can provide guidance on whether the task is appropriate for the nursing assistant to perform. Choice A is incorrect because blindly following a directive that is outside of the nursing assistant's scope could lead to negative consequences. Choice C might not be the best course of action initially, as it's important to seek clarification first. Choice D is also not the best option because performing a task outside of one's role without proper authorization can pose risks to both the patient and the nursing assistant.
A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?
- A. Restrict the patient's fluid intake.
- B. Monitor the patient's daily weight.
- C. Administer diuretics as prescribed.
- D. Increase the patient's salt intake to promote fluid balance.
Correct Answer: B
Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.
A patient is experiencing shortness of breath. What is the nurse's immediate action?
- A. Assist the patient into a high Fowler's position.
- B. Administer oxygen at 2 liters per minute via nasal cannula.
- C. Encourage the patient to take deep breaths and cough.
- D. Assess the patient's lung sounds.
Correct Answer: B
Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.