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A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
- A. Throw the catheter way and begin again.
- B. Fill the balloon with the recommended sterile water.
- C. Remove the catheter, wipe with alcohol, and reinsert after lubrication.
- D. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
Correct Answer: C
Rationale: The correct choice is C because if no urine is obtained, it indicates that the catheter is not in the urethra. The nurse should remove the catheter, wipe with alcohol to maintain cleanliness, and reinsert after lubrication to ensure proper placement in the urethra. This step-by-step approach allows for a more accurate catheter insertion and prevents potential complications.
Choice A is incorrect as discarding the catheter and starting over without addressing the issue does not solve the problem. Choice B is incorrect as filling the balloon with sterile water is not relevant to the situation of catheter misplacement. Choice D is incorrect as leaving the catheter in the vagina can lead to infection and is not a recommended practice.
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The hospice nurse has just admitted a new patient to the program. What principle guides hospice care?
- A. Care addresses the needs of the patient as well as the needs of the family.
- B. Care is focused on the patient centrally and the family peripherally.
- C. The focus of all aspects of care is solely on the patient.
- D. The care team prioritizes the patients physical needs and the family is responsible for the patients emotional needs.
Correct Answer: A
Rationale: The correct answer is A because hospice care is centered on a holistic approach that considers the physical, emotional, social, and spiritual needs of both the patient and their family. This principle recognizes that caring for a terminally ill patient involves supporting the entire family unit. Choice B is incorrect because family support is integral to hospice care. Choice C is incorrect because hospice care extends beyond just the patient to include their loved ones. Choice D is incorrect because the care team should address all aspects of care for both the patient and their family, not prioritize one over the other.
A patient with multiple food and environmental allergies tells the nurse that he is frustrated and angry about having to be so watchful all the time and wonders if it is really worth it. What would be the nurses best response?
- A. I can only imagine how you feel. Would you like to talk about it?
- B. Lets find a quiet spot and Ill teach you a few coping strategies.
- C. Thats the same way that most patients who have a chronic illness feel.
- D. Do you think that maybe you could be managing things more efficiently?
Correct Answer: A
Rationale: The correct answer is A because it shows empathy and offers the patient an opportunity to express their feelings. By acknowledging the patient's frustration and anger, the nurse validates their emotions and creates a safe space for communication. This response promotes trust and understanding, which are crucial in building a therapeutic relationship.
Choice B is incorrect because it immediately jumps to teaching coping strategies without addressing the patient's emotional state. Choice C is incorrect as it generalizes the patient's feelings without directly engaging with their specific concerns. Choice D is incorrect as it sounds dismissive and may make the patient feel judged or misunderstood. These responses lack the empathetic approach needed to effectively support the patient in this situation.
Before giving the patient an intermittent gastric tube feeding, what should the nurse do?
- A. Make sure that the tube is secured to the gown with a safety pin.
- B. Inject air into the stomach via the tube and auscultate.
- C. Have the tube feeding at room temperature.
- D. Check to make sure pH is at least 5
Correct Answer: B
Rationale: The correct answer is B because injecting air into the stomach via the tube and auscultating helps confirm the tube placement in the stomach before administering the feeding. This step ensures the safety of the patient by preventing accidental lung feeding.
Choice A is incorrect because securing the tube with a safety pin to the gown is not a standard practice and can lead to complications.
Choice C is incorrect because the temperature of the feeding does not affect the tube placement or safety.
Choice D is incorrect because checking the pH level is not a reliable method for verifying tube placement.
You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer?
- A. Palliative
- B. Reconstructive
- C. Salvage
- D. Prophylactic
Correct Answer: A
Rationale: The correct answer is A: Palliative surgery. In this scenario, the patient's colon cancer has already progressed to stage IV with metastasis to the liver, indicating an advanced and incurable condition. Palliative surgery aims to alleviate symptoms, improve quality of life, and prolong survival without aiming for a cure. Reconstructive surgery (B) is typically done to restore form or function, which is not the primary goal in this case. Salvage surgery (C) is usually performed to rescue a situation where initial treatment has failed, which is not the case here. Prophylactic surgery (D) is preventive and is not appropriate in a situation where cancer is already present and advanced.
A nurse has made a referral to a grief support group, knowing that many individuals find these both comforting and beneficial after the death of a loved one. What is the most important accomplishment available by attending a grief support group?
- A. Providing a framework for incorporating the old life into the new life
- B. Normalizing adaptation to a continuation of the old life
- C. Aiding in adjusting to using old, familiar social skills
- D. Normalization of feelings and experiences
Correct Answer: D
Rationale: The correct answer is D: Normalization of feelings and experiences. Attending a grief support group helps individuals feel validated and understood by others who are going through similar emotions. This normalization can reduce feelings of isolation and provide a sense of belonging, which is crucial in the grieving process. It also allows individuals to recognize that their feelings and experiences are common reactions to loss.
Choice A is incorrect because a grief support group focuses more on accepting and processing the new reality rather than incorporating the old life into it. Choice B is incorrect as it suggests maintaining the old life rather than adjusting to a new normal. Choice C is incorrect because the focus of a grief support group is not solely on social skills but on emotional support and coping mechanisms.