Nokea
A nurse is preparing to assist with a lumbar epidural steroid injection (LESI) procedure for a patient with chronic back pain. What action should the nurse prioritize to ensure procedural accuracy?
- A. Confirming the patient's identity and procedure site using two identifiers
- B. Positioning the patient in a prone position with a pillow under the abdomen
- C. Providing conscious sedation to the patient to minimize discomfort
- D. Administering local anesthesia to the skin before needle insertion
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Confirming the patient's identity ensures the right patient is receiving the intended procedure.
2. Verifying the procedure site using two identifiers prevents errors in site selection.
3. This step aligns with the World Health Organization's Surgical Safety Checklist, reducing the risk of wrong-site procedures.
4. Positioning, sedation, and local anesthesia are important but secondary to ensuring the correct patient and site.
Summary:
- Option B: Positioning is essential but not the top priority for procedural accuracy.
- Option C: Sedation aims to minimize discomfort but does not guarantee procedural accuracy.
- Option D: Administering local anesthesia is crucial but not as critical as confirming patient identity and procedure site.
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Nurse Victor reviews the medical history of patient Mila. Which of the following conditions is the MOST common cause of cardiogenic shock?
- A. Decreased hemoglobin level
- B. Acute myocardial infarction (MI)
- C. Hypotension
- D. Coronary artery disease
Correct Answer: B
Rationale: The correct answer is B: Acute myocardial infarction (MI) is the most common cause of cardiogenic shock. During an MI, there is significant damage to the heart muscle, leading to a decrease in cardiac output and subsequent shock. This results in inadequate tissue perfusion and oxygen delivery. Choices A, C, and D are incorrect because decreased hemoglobin level (A) may lead to anemia but is not the most common cause of cardiogenic shock. Hypotension (C) is a symptom of shock, not the cause. Coronary artery disease (D) is a risk factor for MI but not the direct cause of cardiogenic shock.
Informed consent in this study will be obtained by Myra from the
- A. six participants only
- B. parents only
- C. six participants and available relative
- D. six participants and their parents
Correct Answer: D
Rationale: The correct answer is D because informed consent should be obtained from both the participants and their parents to ensure full understanding and agreement from all parties involved. This is crucial when working with minors to protect their rights and ensure ethical standards are met. Choice A is incorrect as it excludes parental consent, which is necessary for minors. Choice B is also incorrect as it neglects the participants' direct involvement in consenting to participate. Choice C is incorrect because it only includes available relatives, which may not be legally authorized to provide consent on behalf of the participants.
During surgery, the nurse notices that the patient's blood pressure is trending higher than the baseline. What action should the nurse take?
- A. Administer antihypertensive medication
- B. Document the blood pressure readings in the anesthesia record
- C. Notify the anesthesia provider for further assessment
- D. Continue monitoring the patient's blood pressure closely
Correct Answer: C
Rationale: The correct answer is C: Notify the anesthesia provider for further assessment. This is the most appropriate action because an anesthesia provider is trained to assess and manage changes in blood pressure during surgery. Administering antihypertensive medication (A) without proper assessment can be dangerous. Documenting the readings (B) is important but not the immediate action. Continuing to monitor closely (D) is necessary but notifying the anesthesia provider for further assessment should be the priority.
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.
A patient admitted to the ICU develops acute delirium with agitation and hallucinations. What intervention should the healthcare team prioritize to manage the patient's delirium?
- A. Implement environmental modifications to promote sleep hygiene.
- B. Administer antipsychotic medications for symptom control.
- C. Perform neurological assessments to rule out focal deficits.
- D. Recommend benzodiazepines for sedation and anxiety relief.
Correct Answer: A
Rationale: The correct answer is A: Implement environmental modifications to promote sleep hygiene. Delirium is often triggered by environmental factors like noise, light, and disruption of sleep. By optimizing the environment for rest and minimizing stimuli, the patient's delirium can improve. This approach focuses on addressing the root cause rather than just managing symptoms.
Choice B is incorrect because antipsychotic medications can worsen delirium and are not recommended as first-line treatment.
Choice C is not the priority as ruling out focal deficits may be important but does not directly address the delirium.
Choice D is incorrect as benzodiazepines can exacerbate delirium and are not recommended due to their potential to worsen cognitive function.