Nokea
A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?
- A. Encourage the patient to walk in the hall alone
- B. Discourage the patient from walking in the hall for a few more days
- C. Accompany the patient for his walk
- D. Consult a physical therapist before allowing the patient to ambulate
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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If a patient asks the nurse for her opinion about a particular physician and the nurse replies that the physician is incompetent, the nurse could be held liable for:
- A. Slander
- B. Libel
- C. Assault
- D. Respondent superior
Correct Answer: A
Rationale: In this scenario, if the nurse makes a false verbal statement about the physician being incompetent, it is considered slander. Slander is the act of making defamatory spoken statements or gestures. Libel, on the other hand, refers to defamatory statements that are written or published. Assault involves the threat of physical harm, and respondent superior is a legal doctrine holding an employer responsible for the actions of an employee in the course of employment.
The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.
Which of the following blood tests should be performed before a blood transfusion?
- A. Prothrombin and coagulation time
- B. Blood typing and cross-matching
- C. Bleeding and clotting time
- D. Complete blood count (CBC) and electrolyte levels
Correct Answer: B
Rationale: Before administering a blood transfusion, it is crucial to perform blood typing and cross-matching to ensure compatibility between the donor's blood and the recipient's blood. This process helps prevent adverse reactions such as transfusion reactions, which can be life-threatening. Prothrombin and coagulation time, bleeding and clotting time, as well as CBC and electrolyte levels are important tests in other clinical contexts, but for blood transfusions, blood typing and cross-matching are essential to ensure patient safety.
What is the correct sequence for assessing the abdomen?
- A. Tympanic percussion, measurement of abdominal girth, and inspection
- B. Assessment for distention, tenderness, and discoloration around the umbilicus
- C. Percussion, palpation, and auscultation
- D. Auscultation, percussion, and palpation
Correct Answer: D
Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.
The correct method for determining the vastus lateralis site for I.M. injection is to:
- A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
- B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
- C. Palpate a 1" circular area anterior to the umbilicus
- D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.