Nokea
A clinic nurse is providing patient education prior to a patients scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this?
- A. The patient is not listening effectively.
- B. The patient is noncompliant with the plan of care.
- C. The patient may have a low intelligence quotient or a cognitive deficit.
- D. The patient has not achieved the desired learning outcomes.
Correct Answer: D
Rationale: The correct answer is D. The plausible conclusion the nurse should draw is that the patient has not achieved the desired learning outcomes.
1. The patient's repeated questions indicate a lack of understanding despite the nurse's teaching efforts.
2. This suggests that the patient has not grasped the information provided.
3. It does not necessarily mean the patient is not listening effectively, noncompliant, or has low intelligence.
4. The focus should be on reassessing the teaching methods and providing additional support to help the patient achieve the desired learning outcomes.
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A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond?
- A. Not until the drain is removed
- B. On the second postoperative day
- C. Now, if you wash gently with soap and water
- D. Seven days after your surgery
Correct Answer: A
Rationale: The correct answer is A: Not until the drain is removed. After a mastectomy with immediate reconstruction, there is typically a drain in place to collect fluid. Showering before the drain is removed can increase the risk of infection and disrupt the healing process. It is important to wait until the healthcare provider removes the drain to ensure proper healing and reduce the risk of complications.
Summary:
B: On the second postoperative day - Too early, the drain needs to be removed first.
C: Now, if you wash gently with soap and water - Incorrect, the drain should be removed before showering.
D: Seven days after your surgery - Incorrect, waiting for a specific number of days is not necessary, it depends on when the drain is removed.
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
- A. Herpes simplex
- B. HIV
- C. Spina bifida
- D. Hypogammaglobulinemia
Correct Answer: D
Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems.
Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies.
Choice B: HIV weakens the immune system but is not specifically associated with latex allergies.
Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.
A nurse and a patient work on strategies to reduceweight. Which phase of the helping relationship is the nurse in with this patient?
- A. Preinteraction
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: The correct answer is C: Working. In the working phase, the nurse and patient actively collaborate on achieving goals, such as weight reduction strategies. The nurse assesses, plans, and implements interventions with the patient. During this phase, the focus is on building trust, exploring feelings, and identifying and addressing issues. The other choices are incorrect because in the preinteraction phase (A), there is no direct interaction yet, in the orientation phase (B), the relationship is being established, and in the termination phase (D), the relationship is coming to an end. Thus, the nurse being engaged in weight reduction strategies with the patient indicates that they are in the working phase of the helping relationship.
The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye?
- A. 30 seconds
- B. 1 minute
- C. 3 minutes
- D. 5 minutes
Correct Answer: C
Rationale: The correct answer is C: 3 minutes. After administering the first eye drop, waiting for 3 minutes before instilling the second medication allows for proper absorption and effectiveness of each medication. This interval prevents dilution or interaction between the medications. Option A (30 seconds) is too short, not allowing sufficient time for absorption. Option B (1 minute) is also inadequate for proper absorption. Option D (5 minutes) is unnecessarily long and may lead to patient discomfort or inconvenience.
A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow?
- A. The patient must not have received an immunization within 7 days.
- B. The nurse should administer albuterol 30 to 45 minutes prior to the test.
- C. Prophylactic epinephrine should be administered before the test.
- D. Emergency equipment should be readily available.
Correct Answer: D
Rationale: The correct answer is D. Having emergency equipment readily available is crucial during allergy skin testing as it can lead to severe allergic reactions. This precaution ensures prompt intervention in case of anaphylaxis. Other choices are incorrect because: A) Recent immunizations do not directly impact the skin testing process. B) Administering albuterol is not a standard pre-test requirement. C) Prophylactic epinephrine is not routinely given before allergy skin testing.