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A nurse is delegating tasks to a nursing assistant. What principle should guide the nurse's delegation decisions?
- A. Delegating tasks according to the assistant's job description
- B. Assigning tasks based on the assistant's level of experience
- C. Delegating tasks that the nurse prefers not to perform
- D. Providing tasks that are routine and do not require nursing judgment
Correct Answer: B
Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.
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A patient becomes emotional while discussing their recent diagnosis. What is the nurse's most appropriate response?
- A. Ignore the patient's emotions and continue with the conversation.
- B. Acknowledge the patient's emotions and offer empathy and support.
- C. Tell the patient to stop being emotional and focus on the facts.
- D. Change the subject to avoid further emotional distress.
Correct Answer: B
Rationale: Acknowledging the patient's emotions and offering empathy and support is the most appropriate response in this situation. It is important for the nurse to show understanding and compassion towards the patient, especially when they are feeling emotional about a recent diagnosis. By acknowledging the patient's emotions, the nurse can create a supportive environment that facilitates open communication and helps the patient feel heard and valued. This approach can also help build trust between the patient and the nurse, leading to better outcomes in terms of patient care and overall well-being. Ignoring the patient's emotions, telling them to stop being emotional, or changing the subject may make the patient feel dismissed or isolated, which could negatively impact their mental and emotional state. Thus, offering empathy and support is key in helping the patient cope with their emotions and navigate through their diagnosis.
Which of the following interventions is most appropriate for a patient with a tension pneumothorax?
- A. Needle decompression
- B. Chest tube insertion
- C. High-flow oxygen therapy
- D. Incentive spirometry
Correct Answer: A
Rationale: A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, causing increased pressure in the chest cavity. This can lead to compression of the lung and major blood vessels, leading to inadequate oxygenation and circulation.
A nurse is preparing to perform an intracranial pressure (ICP) monitoring procedure for a patient with traumatic brain injury. What action should the nurse prioritize to ensure procedural accuracy?
- A. Ensuring proper zeroing and calibration of the ICP monitoring system
- B. Positioning the patient in a high-Fowler's position during the procedure
- C. Administering prophylactic antibiotics to prevent infection
- D. Placing the ICP monitor in the subarachnoid space via lumbar puncture
Correct Answer: A
Rationale: The nurse should prioritize ensuring proper zeroing and calibration of the ICP monitoring system to ensure procedural accuracy and reliability of the measurements obtained. Proper zeroing involves setting the transducer at the level of the patient's external auditory meatus (ear), which serves as a reference point for accurate ICP readings. Calibration is necessary to establish accurate pressure measurements. Incorrect zeroing or calibration can lead to inaccurate ICP readings, which can impact clinical decision-making for patients with traumatic brain injury. Positioning the patient in a high-Fowler's position, administering prophylactic antibiotics, or placing the ICP monitor in the subarachnoid space via lumbar puncture are not directly related to ensuring the accuracy of the ICP monitoring procedure.
A patient with a history of chronic kidney disease is prescribed a low-protein diet. Which dietary choice indicates understanding of the prescribed diet?
- A. Grilled salmon
- B. Lentil soup
- C. Beef stew
- D. Chicken Caesar salad
Correct Answer: D
Rationale: A patient with chronic kidney disease prescribed a low-protein diet should avoid high-protein foods like grilled salmon, lentil soup, and beef stew. Chicken Caesar salad, on the other hand, typically contains a smaller amount of protein compared to the other options. This choice indicates an understanding of the need to limit protein intake while still enjoying a balanced meal. However, it is important to note that the quantity and portion sizes of high-protein ingredients in the salad should also be moderate to comply with a low-protein diet.
Nurse Harper observes Evelyn has knowledge deficit regarding fetal nutrition. Nurse Harper has to explain that the MAIN SOURCE of nutrition for the baby is which of the following?
- A. Amniotic fluid
- B. Uterus
- C. Placenta
- D. Chorionic villi
Correct Answer: C
Rationale: The main source of nutrition for the baby during pregnancy is the placenta. The placenta is an organ that develops inside the uterus during pregnancy and provides essential nutrients and oxygen from the mother's blood to the baby through the umbilical cord. It acts as a barrier, protecting the baby from harmful substances while allowing necessary nutrients to pass through. The amniotic fluid serves as a protective cushion for the baby, the uterus provides the space for the baby to grow, and chorionic villi are small, hair-like structures on the placenta that aid in the exchange of nutrients and waste between the mother and the baby. However, the primary source of nutrition for the baby is the placenta, making option C the correct answer in this scenario.