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A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?
- A. Notify the family and await further instructions.
- B. Initiate CPR and call for emergency assistance.
- C. Allow the family to make decisions about care.
- D. Follow the family's wishes and perform no interventions.
Correct Answer: B
Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.
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A nurse notices that a colleague has an odor of alcohol while on duty. What is the most appropriate action?
- A. Speak to the colleague in private.
- B. Report the behavior to the nurse manager immediately.
- C. Confront the colleague directly on the floor.
- D. Do nothing and document the situation.
Correct Answer: B
Rationale: Reporting the behavior to the nurse manager immediately is the most appropriate action when a nurse suspects a colleague of being impaired while on duty. This is crucial to ensure patient safety and maintain a professional and safe work environment. Speaking to the colleague in private may not address the issue effectively and could potentially put patients at risk if the colleague is indeed impaired. Confronting the colleague directly on the floor may lead to a confrontation and is not the most professional way to handle the situation. Doing nothing and documenting the situation without taking immediate action can jeopardize patient safety and is not an appropriate response when substance use is suspected.
The nurse is evaluating the effectiveness of guided imagery for pain management in a patient with second- and third-degree burns requiring extensive dressing changes. Which finding best indicates the effectiveness of guided imagery?
- A. The patient's need for analgesic medication decreases during the dressing changes.
- B. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.
- C. The patient asks for pain medication during the dressing changes only once throughout the procedure.
- D. The patient's facial expressions remain stoic during the procedure.
Correct Answer: A
Rationale: The correct answer is A. A reduction in the need for analgesic medication indicates that guided imagery is effective in managing the patient's pain. Choices B, C, and D do not directly measure the effectiveness of guided imagery. A patient rating pain as 6 on a scale of 0 to 10, asking for pain medication once, or having stoic facial expressions may not necessarily reflect the impact of guided imagery on pain management.
When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?
- A. Proceed with the surgery and document the refusal.
- B. Ask the patient for permission to secure the jewelry safely.
- C. Tape the jewelry to the patient's body during surgery.
- D. Tell the patient they must remove the jewelry for safety reasons.
Correct Answer: B
Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.
A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?
- A. Use sterile gloves during the procedure.
- B. Clean the catheter insertion site with alcohol.
- C. Insert the catheter as quickly as possible.
- D. Use a smaller catheter size to minimize trauma.
Correct Answer: A
Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.
A patient with heart failure needs education on fluid restrictions. What is the most important information to provide?
- A. Monitor the patient's weight daily.
- B. Provide the patient with a fluid restriction plan.
- C. Instruct the patient to avoid salty foods.
- D. Encourage the patient to increase fluid intake.
Correct Answer: B
Rationale: The most important information to provide to a patient with heart failure regarding fluid restrictions is to provide them with a fluid restriction plan. This plan helps the patient manage their fluid intake effectively, which is crucial in preventing complications associated with heart failure. Monitoring weight daily can be a part of the plan but is not the most important. Instructing the patient to avoid salty foods is beneficial but not as crucial as having a structured fluid restriction plan. Encouraging the patient to increase fluid intake would be counterproductive and potentially harmful in a patient with heart failure.