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A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?
- A. Bring the IV kit and quickly start an IV
- B. Assess his breathing and provide oxygen, if necessary
- C. Administer medication to control chest pain
- D. Talk with his wife and find out why she is crying
Correct Answer: B
Rationale: The correct answer is B: Assess his breathing and provide oxygen if necessary. This is the first action the client should take because the patient is presenting with chest pain and difficulty breathing, which could indicate a serious medical condition like a heart attack or pulmonary embolism. By assessing the patient's breathing and providing oxygen if needed, the client can help stabilize the patient's condition and ensure proper oxygenation. Starting an IV or administering medication should come after assessing and stabilizing the patient's respiratory status. Talking with the wife, while important for gathering information, is not the priority in this situation.
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Which of the following may be a cultural barrier that impacts a healthcare provider's ability to provide care or education to the client?
- A. A healthcare provider offers educational materials to a client that are written at an 8th-grade reading level
- B. A Vietnamese woman wants to use steaming in addition to her prescription antibiotics
- C. A healthcare provider uses pantomime to explain a procedure to a deaf client
- D. A Native American client requests a healing ritual before considering surgery
Correct Answer: C
Rationale: The correct answer is C because using pantomime to explain a procedure to a deaf client is a cultural barrier. Deaf individuals may use sign language or have different communication preferences, so relying solely on pantomime may not effectively convey the necessary information. This can lead to misunderstandings or incomplete communication, impacting the quality of care provided.
Choice A is incorrect as offering materials at an 8th-grade reading level is a best practice in health literacy and not a cultural barrier. Choice B may reflect cultural preferences but does not necessarily impede the provider's ability to provide care. Choice D involves a client's spiritual beliefs but does not directly hinder the provider's ability to provide care.
At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?
- A. A diabetic client with a blood glucose level of 195 mg/dL
- B. A family member of an elderly client who has questions
- C. A client with COPD with an oxygen saturation of 84%
- D. A client who requires assistance to use the bathroom
Correct Answer: C
Rationale: The correct answer is C: A client with COPD with an oxygen saturation of 84%. Oxygen saturation below 90% is considered critical, indicating hypoxemia in a client with COPD. Priority is given to critical physiological needs to avoid potential respiratory distress or failure. Choices A, B, and D are important but do not pose immediate life-threatening risks. The diabetic client with a blood glucose level of 195 mg/dL can be managed with insulin administration. The family member's questions can be addressed after addressing immediate client needs. The client who requires assistance to use the bathroom can be attended to once the critical client's needs are addressed. Prioritizing based on physiological urgency ensures client safety.
A client asks a nurse, 'Do you think I should move back home after this procedure?' and the nurse responds by saying, 'Do you think you should move back home?' What type of therapeutic communication is the nurse representing?
- A. Observation
- B. Reflection
- C. Summarizing
- D. Validating
Correct Answer: B
Rationale: The correct answer is B: Reflection. Reflection involves paraphrasing the client's words to help them explore their feelings and thoughts. In this scenario, the nurse is reflecting the client's question back to them, encouraging self-exploration. Observation (A) involves stating what the nurse sees or hears without interpretation. Summarizing (C) involves condensing information. Validating (D) involves confirming the client's feelings or experiences. The nurse's response does not align with the other options, making reflection the best choice.
A nursing unit is implementing a new electronic charting program for the nursing staff to use. Which of the following best describes a disadvantage of using electronic charting?
- A. The information is more likely to be lost or used inappropriately.
- B. Any provider in the unit can have access to the client's medical records.
- C. The system diminishes communication between nurses and providers.
- D. The program may be confusing and difficult to implement.
Correct Answer: D
Rationale: The correct answer is D: The program may be confusing and difficult to implement. Implementing a new electronic charting program may be challenging due to the complexity of the software and the learning curve for staff. It can take time and resources to train employees on how to effectively use the program, leading to potential confusion and resistance to change. This disadvantage could result in delays in charting, errors, and frustrations among staff members.
Other choices are incorrect because:
A: The information is more likely to be lost or used inappropriately - Electronic charting systems often have built-in security measures to prevent data loss and unauthorized access.
B: Any provider in the unit can have access to the client's medical records - Electronic charting systems have role-based access control to limit who can view specific patient information.
C: The system diminishes communication between nurses and providers - Electronic charting can actually improve communication by allowing real-time access to patient information.
A nurse is using active listening as a form of therapeutic communication when:
- A. She uses humor to put the client at ease in a situation
- B. She restates what the client said in slightly different words
- C. She uses eye contact and maintains an open stance while the client is talking
- D. She provides personal information to show the client she can relate to him
Correct Answer: C
Rationale: The correct answer is C because using eye contact and maintaining an open stance while the client is talking demonstrates active listening. Eye contact shows attentiveness and respect, while an open stance conveys empathy and receptiveness. This non-verbal communication encourages the client to feel heard and understood, fostering a therapeutic relationship.
Choice A is incorrect because using humor may not always align with the client's feelings or be perceived as appropriate. Choice B is incorrect as restating what the client said is a form of paraphrasing, not active listening. Choice D is incorrect because providing personal information can shift the focus away from the client's needs and may breach professional boundaries.