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A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The patient has visitors in the room. What should the nurse do?
- A. Ask the visitors to leave the room.
- B. Ask the patient if visitors should remain in the room.
- C. Tell the patient to ask the visitors to leave the room.
- D. Wait until the visitors leave to begin the procedure.
Correct Answer: B
Rationale: The nurse should ask the patient if visitors should remain, respecting patient autonomy and privacy preferences during the procedure.
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Which of the following statements accurately describe a recommended guideline for implementation? Select all that apply.
- A. When implementing nursing care, remember to act independently, regardless of the wishes of the patient/family.
- B. Before implementing any nursing action, reassess the patient to determine whether the action is still needed.
- C. Assume that the nursing intervention selected is the best of all possible alternatives.
- D. Consult colleagues and the nursing and related literature to see if other approaches might be more successful.
- E. Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.
- F. Check to make sure that the nursing interventions selected are consistent with standards of care.
Correct Answer: B,D,F
Rationale: Recommended guidelines include reassessing the patient (B), consulting colleagues and literature for better approaches (D), and ensuring interventions align with standards of care (F). Acting independently without patient input (A), assuming interventions are the best (C), or reducing skills (E) are not recommended.
A nurse is catheterizing a patient. What action illustrates respect for the patients privacy?
- A. explaining the procedure to the family
- B. leaving the patients pajamas on
- C. closing the door to the room
- D. asking another nurse if he wants to watch
Correct Answer: C
Rationale: Closing the door to the room ensures privacy by limiting exposure to others, a key aspect of respecting patient dignity during invasive procedures.
A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean?
- A. The nurse is using critical thinking to implement the dressing change.
- B. The patient has specified how the dressing should be changed.
- C. Written plans are developed that specify nursing activities for this skill.
- D. The physician verbally requested specific steps of the dressing change.
Correct Answer: C
Rationale: An established protocol means written plans specify the nursing activities for the procedure, ensuring standardized and evidence-based practice.
What role of the nurse is crucial to the prevention of fragmentation of care?
- A. advocate
- B. teacher
- C. counselor
- D. coordinator
Correct Answer: D
Rationale: The coordinator role is crucial to prevent fragmentation of care, as it involves organizing and integrating services from multiple healthcare providers to ensure continuity.
What characteristic of a competent nurse practitioner enables nurses to be role models for patients?
- A. sense of humor
- B. writing ability
- C. organizational skills
- D. good personal health
Correct Answer: D
Rationale: Good personal health enables nurses to model healthy behaviors, serving as role models for patients in promoting wellness.