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A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first?
- A. Perform oral suctioning.
- B. Page the physician.
- C. Insert a tongue depressor into the patients mouth.
- D. Turn the patient on his side.
Correct Answer: D
Rationale: When a patient is experiencing a seizure and begins vomiting, the priority action for the nurse is to turn the patient onto their side. This position helps to prevent aspiration, which can occur when the patient inhales vomit into their lungs. Turning the patient on their side allows for the vomit to drain out of the mouth, reducing the risk of aspiration and maintaining a clear airway. Performing oral suctioning would be necessary after turning the patient on their side, but it is not the initial priority in this situation. Paging the physician and inserting a tongue depressor are not appropriate actions during a seizure and vomiting episode.
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A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy?
- A. Administer an antiemetic.
- B. Administer an antimetabolite.
- C. Administer a tumor antibiotic.
- D. Administer an anticoagulant.
Correct Answer: A
Rationale: Nausea and vomiting are common adverse effects of chemotherapy. Administering an antiemetic helps to prevent or reduce these symptoms in patients undergoing chemotherapy. By managing nausea and vomiting, the patient's overall well-being and quality of life during treatment can be improved. Therefore, providing an antiemetic medication is essential in combating these adverse effects and promoting patient comfort and compliance with treatment.
The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. Thecpatient states that she is having severe pain that had a sudden onset. What is the nurses most appropriate action?
- A. Palpate the surgical site.
- B. Remove the dressing to assess the surgical site.
- C. Call the surgeon to report the patients pain.
- D. Administer a dose of an NSAID.
Correct Answer: C
Rationale: In this scenario, the patient who has had a cervical diskectomy is experiencing severe pain with a sudden onset, which can be indicative of a complication such as bleeding, infection, or nerve impingement. The nurse's most appropriate action is to call the surgeon immediately to report the patient's pain. The surgeon needs to be informed promptly so that a further assessment can be made and appropriate interventions can be initiated to address the cause of the sudden pain. Palpating the surgical site or removing the dressing without consulting the surgeon first may worsen the situation or increase the risk of complications. Administering an NSAID is not appropriate in this situation without further evaluation and guidance from the surgeon. It is essential to prioritize patient safety and ensure that the patient receives timely and appropriate care by involving the surgeon in the decision-making process.
A patients daughter has asked the nurse about helping him end his terrible suffering. The nurse is aware of the ANA Position Statement on Assisted Suicide, which clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. What does the Position Statement further stress?
- A. Educating families about the moral implications of assisted suicide
- B. Identifying patient and family concerns and fears
- C. Identifying resources that meet the patients desire to die
- D. Supporting effective means to honor the patients desire to die
Correct Answer: B
Rationale: The ANA Position Statement on Assisted Suicide stresses the importance of identifying patient and family concerns and fears. This reflects the nurse's responsibility to provide holistic care and support to patients and their families who may be struggling with end-of-life decisions. By identifying concerns and fears, the nurse can address these issues through compassionate communication, education, and appropriate interventions. This proactive approach aligns with the ethical principles of beneficence and nonmaleficence in nursing practice.
A middle-aged female patient has been offered testing for HIV/AIDS upon admission to the hospital for an unrelated health problem. The nurse observes that the patient is visibly surprised and embarrassed by this offer. How should the nurse best respond?
- A. Most women with HIV dont know they have the disease. If you have it, its important we catch it early.
- B. This testing is offered to every adolescent and adult regardless of their lifestyle, appearance or history.
- C. The rationale for this testing is so that you can begin treatment as soon as testing comes back, if its positive.
- D. Youre being offered this testing because you are actually in the prime demographic for HIV infection.
Correct Answer: B
Rationale: Option B is the best response for the nurse to provide in this situation. By stating that the testing is offered to every adolescent and adult regardless of lifestyle, appearance, or history, the nurse conveys that HIV testing is a standard practice and not targeting the patient specifically. This can help reduce the patient's feeling of embarrassment or stigma associated with the offer of testing. It also emphasizes the importance of universal screening for HIV to promote early detection and treatment, regardless of risk factors or demographics. This response helps maintain the patient's dignity and encourages them to consider the testing in a non-judgmental way.
A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor?
- A. Womens knowledge of how their breasts normally look and feel
- B. The rapport that exists between the woman and her primary care provider
- C. Synchronizing womens routines around BSE with the performance of mammograms
- D. Womens knowledge of the pathophysiology of breast cancer
Correct Answer: A
Rationale: Effective breast self-examination (BSE) relies significantly on women's knowledge of their own breasts. Understanding how their breasts normally look and feel allows women to detect any changes such as lumps, dimpling, or discharge, which may be early signs of breast abnormalities like cancer. By being familiar with their breasts' normal appearance and texture, women can promptly seek medical attention if they notice any unusual changes. This self-awareness and familiarity with their breasts are crucial in enabling women to perform BSE effectively and to detect any potential issues early on.