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A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?
- A. Administer a diuretic as prescribed.
- B. Place the patient in a high Fowler's position.
- C. Administer oxygen via nasal cannula.
- D. Monitor the patient's lung sounds every 2 hours.
Correct Answer: B
Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.
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A client is about to undergo surgery and is unsure about the procedure despite signing the consent. What should the nurse do?
- A. Reassure the client and proceed with the surgery.
- B. Stop the surgery and consult with the surgeon.
- C. Proceed with the surgery but document the client's concerns.
- D. Postpone the surgery until further clarification is provided.
Correct Answer: B
Rationale: When a client expresses doubts about a procedure after signing the consent form, it is crucial to stop the surgery and consult with the surgeon. This is important to ensure that the client's concerns are addressed, and there is a clear understanding of the procedure. Reassuring the client and proceeding with the surgery (choice A) may violate the client's autonomy and right to informed consent. Proceeding with the surgery but documenting the concerns (choice C) is not sufficient as the client's doubts should be resolved before proceeding. Postponing the surgery until further clarification is provided (choice D) may be necessary, but the immediate step should be to consult with the surgeon to address the client's concerns.
A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?
- A. Give detailed information about the medication, including its potential side effects.
- B. Refer the client to the healthcare provider for more information.
- C. Give a brief explanation and administer the medication.
- D. Ask another nurse to explain the medication and proceed.
Correct Answer: B
Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.
When considering a bone marrow transplant for a client with leukemia, which ethical principle pertains to minimizing harm to the client?
- A. Justice
- B. Nonmaleficence
- C. Autonomy
- D. Beneficence
Correct Answer: B
Rationale: The correct answer is B: Nonmaleficence. Nonmaleficence is the ethical principle that emphasizes the obligation to do no harm, making it crucial in medical decision-making. In the context of a bone marrow transplant for a client with leukemia, the primary concern is to minimize harm and avoid causing any unnecessary suffering or adverse effects. Choices A, C, and D are incorrect: Justice relates to fairness in resource allocation and treatment decisions, Autonomy involves respecting the patient's right to make decisions about their own care, and Beneficence refers to the obligation to act in the patient's best interest and promote their well-being, which may involve some level of risk or harm for overall benefit.
A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?
- A. The nursing student wears gloves when changing bed linens.
- B. The nursing student wears gloves to remove a wound dressing.
- C. The nursing student washes hands after removing gloves.
- D. The nursing student touches the patient's skin with sterile gloves.
Correct Answer: D
Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.
The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?
- A. Donning sterile gown and gloves to remove the wound dressing
- B. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
- C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
- D. Donning clean goggles, gown, and gloves to dress the wound
Correct Answer: C
Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.