Nokea
A home care nurse is observing the patient's family member perform a wound irrigation and dressing change for a postoperative wound dehiscence containing purulent drainage. In which situation will the nurse provide additional education?
- A. The family member places the old dressing in a separate bag at the bedside.
- B. The patient takes an analgesic a half-hour prior to the dressing change.
- C. The family member states they washed their hands an hour ago.
- D. The patient returns to bed during the dressing change.
Correct Answer: C
Rationale: The nurse teaches the patient and family to effectively wash their hands before and after having direct contact with the patient, before performing invasive procedures, when handling dressing or touching open wounds, and when administering medications or feeding the patient. All other options are correct.
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A nurse on a medical-surgical unit is teaching a patient's family about hospice care. How does the nurse best explain the focus of this care?
- A. Hospice care focuses on symptom and pain relief.
- B. Nutrition is provided orally or by tube to maintain intake.
- C. Surgical procedures are performed when medically necessary.
- D. Services are provided until the patient's death.
Correct Answer: A
Rationale: Hospice services include pain management, physician and nurse practitioner services, spiritual support, respite services, and bereavement counseling.
A discharge nurse is evaluating patients and their families to determine the need referrals to other facilities after hospitalization. Which patients will the nurse recommend for these services? Select all that apply.
- A. Older adult diagnosed with dementia in the hospital
- B. Adult diagnosed with Parkinson disease
- C. Adult woman receiving chemotherapy for breast cancer
- D. Adolescent being discharged with a cast on his leg
- E. New mother who delivered a healthy infant via a cesarean birth
- F. Adult man diagnosed with end-stage cancer
Correct Answer: A,B,F
Rationale: The patients who are most likely to need a formal discharge plan or referral to another facility are those who are emotionally or mentally unstable (e.g., those with dementia), those who have recently diagnosed chronic disease (e.g., Parkinson disease), and those who have a terminal illness (e.g., end-stage cancer). Other candidates include patients who do not understand the treatment plan, are socially isolated, have had major surgery or illness, need a complex home care regimen, or lack financial services or referral sources.
A nurse is considering moving from the hospital setting to home health care. In speaking with other professionals, what qualities does the nurse find they should possess to be successful? Select all that apply.
- A. Making accurate assessments
- B. Researching new treatments for chronic diseases
- C. Communicating effectively
- D. Delegating tasks appropriately
- E. Performing clinical skills effectively
- F. Making independent decisions
Correct Answer: A,C,E,F
Rationale: Nurses working in the community must have the knowledge and skills to make accurate assessments, work independently, communicate effectively, and perform clinical skills accurately. Community-based nurses may be researchers and occasionally delegate care, but these are not key qualities for this type of nursing.
A nurse is reviewing the discharge plan with a patient who had major abdominal surgery. Which statement by the nurse is most appropriate?
- A. I'll bet you will be so glad to be home and sleep in your own bed.
- B. Tell me about your understanding of your recovery needs after discharge.
- C. Be sure to take your pain medications and change your dressing.
- D. You will just be fine! Please stop worrying.
Correct Answer: B
Rationale: The purpose of discharge planning is to ensure for continuity of care for the patient and family needs. The nurse uses open-ended assessment questions to begin a planning session. Essential components of discharge planning include assessing the strengths and limitations of the patient, the family or support person, and the environment; implementing and coordinating the care plan; considering individual, family, and community resources; and evaluating the effectiveness of care. Answers a and c are examples of communication or interventions, which may be included after an assessment. The statement 'You will just be fine! Please stop worrying,' is a clich?© and is avoided.
A nurse and AP are planning to receive a patient who sustained a traumatic head injury in a motor vehicle accident. Which activity can the nurse safely delegate to the AP?
- A. Collecting information for a health history
- B. Performing a physical assessment
- C. Contacting the health care provider for medical orders
- D. Preparing the bed and collecting needed supplies
Correct Answer: D
Rationale: The nurse may delegate preparation of the bed and collection of needed supplies to assistive personnel but performs the other activities listed, as they require clinical judgment and specialized skills.