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A nurse in the emergency department is attending to a patient exhibiting symptoms of a myocardial infarction. Which of the following actions should the nurse prioritize? Which action should the nurse prioritize for myocardial infarction?
- A. Initiate oxygen therapy.
- B. Obtain a blood sample.
- C. Attach the leads for a 12-lead ECG.
- D. Insert an IV catheter.
Correct Answer: A
Rationale: The correct answer is A: Initiate oxygen therapy. In a myocardial infarction, the priority is to ensure adequate oxygen supply to the heart muscle to prevent further damage. Oxygen therapy helps increase oxygen delivery to the heart, reducing the workload on the heart muscle. This action can potentially limit the size of the infarction and improve the patient's outcome. Obtaining a blood sample (B) can provide valuable information but is not as urgent as ensuring oxygen supply. Attaching leads for a 12-lead ECG (C) is important for diagnosing the myocardial infarction but does not directly address the immediate need for oxygen. Inserting an IV catheter (D) may be necessary for administering medications, but oxygen therapy takes precedence in this situation.
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A nurse is caring for a patient who has a new prescription for sertraline. Which of the following instructions should the nurse include? What instructions should the nurse include for sertraline?
- A. Take the medication at bedtime.
- B. Take the medication with food.
- C. Avoid driving for the first week.
- D. Report any weight loss.
Correct Answer: A
Rationale: The correct answer is A: Take the medication at bedtime. Sertraline is an antidepressant that is commonly prescribed to be taken in the evening or at bedtime because it can cause drowsiness. This timing helps minimize potential side effects such as dizziness or drowsiness during waking hours. Taking it at bedtime also helps with patient compliance. Choice B is incorrect because sertraline can be taken with or without food. Choice C is incorrect as there is no specific need to avoid driving only for the first week. Choice D is incorrect because weight loss is not a common side effect of sertraline and does not need to be reported.
A nurse manager is providing staff education about working with patients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? What should the nurse include in aggression training?
- A. Stand directly in front of the patient when talking.
- B. Know the layout of the facility.
- C. Bring security with you for all patient interactions.
- D. Provide immediate verbal feedback for escalating behavior.
- E. Avoid wearing necklaces during patient care.
Correct Answer: B,D,E
Rationale: Correct Answer: B, D, E
Rationale:
B: Knowing the layout of the facility is important for quick escape routes and safety measures during a patient's aggressive outburst.
D: Providing immediate verbal feedback for escalating behavior can help in de-escalating the situation and preventing further aggression.
E: Avoiding wearing necklaces during patient care can prevent them from being used as a weapon or trigger for aggressive behavior.
Summary:
A: Standing directly in front of the patient can be confrontational and escalate the situation.
C: Bringing security for all patient interactions may not be feasible or necessary in every situation.
F, G: No additional options are provided, but they would likely be incorrect as they were not included in the correct answer choices.
A nurse is conducting a patient's history and physical examination. Which information should the nurse consider as subjective data? Which information is subjective data?
- A. Petechiae
- B. Nausea
- C. Cyanosis
- D. Fever
Correct Answer: B
Rationale: Subjective data is information provided by the patient based on their feelings, perceptions, or beliefs. Nausea falls under this category as it is a symptom that the patient experiences and reports subjectively. Petechiae, cyanosis, and fever are objective data as they can be observed or measured directly. Petechiae are small red or purple spots on the skin, cyanosis is a bluish discoloration of the skin due to lack of oxygen, and fever is an elevated body temperature, all of which can be confirmed through visual inspection or measurement. Therefore, choice B, nausea, is the correct answer as it relies on the patient's subjective experience.
A nurse is caring for a patient whose right leg is in Buck's traction. Which interventions should the nurse implement to promote the patient's mobility? Which intervention promotes mobility in Buck's traction?
- A. Perform passive range of motion exercises on the right leg.
- B. Perform isometric exercises on both legs.
- C. Perform active range-of-motion exercises on the left leg.
- D. Log roll the patient every 2 hours.
Correct Answer: C
Rationale: Rationale: Performing active range-of-motion exercises on the left leg promotes mobility in Buck's traction by maintaining muscle strength and joint flexibility, preventing muscle atrophy, and improving circulation. This helps prevent complications and supports eventual rehabilitation. Passive range of motion exercises on the right leg are not recommended as it may cause discomfort. Isometric exercises on both legs may not address the specific immobilization of the right leg. Log rolling every 2 hours is not directly related to promoting mobility in Buck's traction.
A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The patients in her assignment are stable. Which of the following legal torts applies to this situation? Which legal tort applies to leaving shift early without permission?
- A. Negligence
- B. Battery
- C. Slander
- D. Libel
Correct Answer: A
Rationale: The correct answer is A: Negligence. Leaving the shift early without permission constitutes negligence as it is a breach of the duty of care owed to the patients. The nurse has a legal responsibility to provide care for the patients until properly relieved. The other choices, Battery, Slander, and Libel, do not apply in this scenario. Battery involves intentional harmful or offensive contact without consent, Slander involves spoken defamation, and Libel involves written defamation. In this case, the nurse's actions do not align with the elements of these torts.