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A nurse is conducting an admission assessment for a newly admitted patient. What aspect of cultural competence should the nurse prioritize during the assessment?
- A. Assuming that the patient shares the nurse's cultural beliefs
- B. Asking the patient about their cultural background and preferences
- C. Avoiding discussions about cultural differences to prevent discomfort
- D. Disregarding the patient's cultural practices and beliefs
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Asking the patient about their cultural background and preferences shows respect for their individuality and acknowledges the importance of cultural competence in providing person-centered care.
2. It allows the nurse to gain valuable insights into the patient's beliefs, values, and practices, enabling them to deliver culturally appropriate care.
3. By prioritizing this aspect, the nurse can establish rapport, build trust, and enhance communication with the patient, leading to better outcomes.
4. Choices A, C, and D are incorrect as they either involve assumptions, avoidance, or disregard for the patient's cultural background, which can lead to misunderstandings, discomfort, and ineffective care.
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In providing tracheostomy care which of the following is the nurse's PRIORITY nursing action? The nurse ________.
- A. Cuts the dressing using sterile scissors
- B. Clean the incisions with iodine-based antiseptic
- C. Secures clean ties before removing soiled ones
- D. Uses clean technique
Correct Answer: C
Rationale: The correct answer is C: Secures clean ties before removing soiled ones. This is the priority action because securing clean ties prevents accidental dislodgement of the tracheostomy tube, ensuring the patient's airway remains patent. Cutting the dressing (A) or cleaning the incisions (B) can be important but not as critical as securing the tube. Using clean technique (D) is essential but not the priority in this situation.
The physician inserted a chest tube drainage to Mr. Alda in order to help re-expand the lungs. Which of the following should you prepare FIRST as a nurse in case of emergency when the tube is accidentally disconnected?
- A. sterile clamps
- B. Sterile dressing.
- C. Another chest tube
- D. A bottle of sterile water.
Correct Answer: A
Rationale: Correct Answer: A - sterile clamps
Rationale:
1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space.
2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space.
3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection.
4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation.
Summary of other choices:
B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space.
C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube.
D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.
To promote drainage and reduce pressure from fluid, Nurse Selma nursing intervention is to have the child assume any of the following positions, EXCEPT _____.
- A. tilt head to side if sitting up.
- B. Lie on the affected area
- C. put the pillows behind the head
- D. lie on the non-affected ear.
Correct Answer: B
Rationale: The correct answer is B: Lie on the affected area. This position would hinder drainage and increase pressure on the affected area. A: Tilt head to the side if sitting up, is correct as it promotes drainage. C: Putting pillows behind the head can also aid drainage. D: Lying on the non-affected ear can help reduce pressure on the affected side.
Which of the following situation is an example of incongruent message?
- A. When the nurse means what she says
- B. When the words and behavior of the nurse agree
- C. When what the nurse says and does do not agree
- D. When content and process agree
Correct Answer: C
Rationale: Step 1: Incongruent message occurs when verbal and nonverbal communication do not align.
Step 2: Choice C states "When what the nurse says and does do not agree," indicating a lack of alignment.
Step 3: This inconsistency can lead to confusion or mistrust in communication.
Step 4: Choices A, B, and D all describe situations with alignment between words and actions, making them congruent.
Summary: Choice C is correct as it exemplifies incongruent communication, while Choices A, B, and D are incorrect as they describe congruent messages.
Nurse Chona read in one nurse's notes chart this documentation: "Refused to eat and fell from bed". Which of the following is lacking in this documentation?
- A. Time of complaint, for missed and reaction on fall incurred.
- B. Referrals made on fall medications given and reasons of falling.
- C. Contents or complaints, reasons of refusing meal and nature of fall.
- D. Time of eating, medications for back pain and intense of pain.
Correct Answer: C
Rationale: The correct answer is C because the documentation lacks essential details regarding the contents of the complaints, reasons for refusing the meal, and the nature of the fall. This information is crucial for understanding the patient's condition and providing appropriate care. Choice A is not directly related to the documentation provided. Choice B is about referrals and medications, which are not mentioned in the documentation. Choice D is about eating time and medications for pain, which are also not relevant to the documentation provided. Therefore, the correct answer is C as it addresses the specific missing information in the nurse's notes.