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A nurse is preparing to administer medications to a patient and discovers a discrepancy between the medication order and the patient's medication record. What is the nurse's priority action?
- A. Administer the medication as ordered to avoid delays
- B. Document the discrepancy and inform the charge nurse
- C. Verify the medication order with the prescriber immediately
- D. Contact the pharmacy for clarification on the medication
Correct Answer: C
Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.
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A patient with a history of heart failure is prescribed digoxin. Which assessment finding indicates a potential adverse effect of digoxin therapy?
- A. Bradycardia
- B. Hypotension
- C. Hyperkalemia
- D. Confusion
Correct Answer: D
Rationale: Confusion is a potential adverse effect of digoxin therapy. Digoxin toxicity can manifest as various central nervous system symptoms, including confusion, delirium, and disorientation. It is important to monitor for signs of digoxin toxicity in patients taking this medication, especially those with a history of heart failure or renal impairment. Other common signs of digoxin toxicity may include visual disturbances (like halos around lights), gastrointestinal symptoms (like nausea and vomiting), and cardiac arrhythmias. Monitoring serum digoxin levels can help guide therapy and identify toxicity early.
A patient undergoing mechanical ventilation in the ICU develops ventilator-associated pneumonia (VAP). What intervention should the healthcare team prioritize to manage the patient's respiratory infection?
- A. Administer broad-spectrum antibiotics targeting common pathogens.
- B. Perform endotracheal suctioning to clear airway secretions.
- C. Implement oral hygiene measures to reduce bacterial colonization.
- D. Recommend early mobilization to prevent complications of immobility.
Correct Answer: A
Rationale: Ventilator-associated pneumonia (VAP) is a serious complication in patients receiving mechanical ventilation in the ICU. The priority intervention to manage respiratory infection in a patient with VAP is the administration of appropriate antibiotics to target and eliminate the causative pathogens. Broad-spectrum antibiotics are usually initiated empirically to cover a wide range of potential pathogens commonly associated with VAP, such as Pseudomonas aeruginosa, Staphylococcus aureus, and Acinetobacter species. Timely initiation of antibiotic therapy is crucial in improving outcomes and reducing morbidity and mortality associated with VAP. Other interventions like endotracheal suctioning, oral hygiene measures, and early mobilization are also important in preventing complications and promoting recovery, but the primary focus should be on treating the infection with antibiotics.
A patient with advanced heart failure expresses fear and anxiety about the progression of their illness. What is the palliative nurse's most appropriate response?
- A. Provide reassurance and minimize discussions about end-of-life care.
- B. Encourage the patient to focus on positive thoughts and avoid discussing fears.
- C. Offer empathetic listening and explore the patient's concerns about the future.
- D. Suggest distraction techniques to divert the patient's attention from their worries.
Correct Answer: C
Rationale: The palliative nurse's most appropriate response in this scenario is to offer empathetic listening and explore the patient's concerns about the future. By providing a compassionate and supportive environment for the patient to express their fears and anxieties, the nurse can help the patient feel heard and understood. This approach allows the nurse to address the patient's emotional needs and provide appropriate support to help them cope with their feelings. Avoiding discussions or minimizing the patient's concerns may invalidate their emotions and hinder the therapeutic relationship. Encouraging distraction techniques or focusing solely on positive thoughts may not address the underlying fears and anxieties that the patient is experiencing. Therefore, offering empathetic listening and exploring the patient's concerns is the most appropriate way for the nurse to provide holistic care for the patient with advanced heart failure.
During the surgical procedure, the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form. What should the nurse do?
- A. Proceed with the procedure as planned
- B. Document the discrepancy in the patient's chart
- C. Inform the surgeon and anesthesia provider immediately
- D. Request clarification from the patient and family members
Correct Answer: C
Rationale: If the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form, the immediate action should be to inform the surgeon and anesthesia provider. It is crucial to address any discrepancies before proceeding with the surgical procedure to ensure patient safety and prevent any potential errors or complications. The surgical team needs to be made aware of the issue so that they can verify the correct patient information and ensure that all necessary steps are taken to proceed safely. Communication and collaboration among the healthcare team members are essential in such situations to prevent any harm to the patient.
After washing her hands and gently cleaning any discharge that can be removed easily from the outer ear, Nurse Selma positions the child. Which of the following steps follows?
- A. Gently press the tragus of the ear four times in a pumping motion.
- B. Gently pull the outer ear
- C. Drop the medicine into the ear canal.
- D. Keep the ear up for five minutes.
Correct Answer: C
Rationale: The correct next step after positioning the child is to drop the medicine into the ear canal. This is typically the next step in administering ear drops for a child. The cleaning and positioning steps are to prepare the ear for receiving the medication. Dropping the medicine into the ear canal ensures that the medication can reach the affected area effectively. Once the medicine is dropped into the ear canal, it is important to follow any additional instructions provided by the healthcare provider regarding keeping the ear in a certain position or any other post-administration care steps.