Nokea
A nurse is preparing to lavage a patient in theemergency department for an overdose. Which tube should the nurse obtain?
- A. Ewald
- B. Dobhoff
- C. Miller-Abbott
- D. Sengstaken-Blakemore
Correct Answer: A
Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach.
Summary of why the other choices are incorrect:
B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage.
C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage.
D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.
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A patient has just been told that her illness is terminal. The patient tearfully states, I cant believe I am going to die. Why me? What is your best response?
- A. I know how you are feeling.
- B. You have lived a long life.
- C. This must be very difficult for you.
- D. Life can be so unfair.
Correct Answer: C
Rationale: The correct answer is C: "This must be very difficult for you." This response acknowledges the patient's emotional state and shows empathy without making assumptions or dismissing their feelings. It validates the patient's emotions and opens up the opportunity for further discussion or support.
Rationale:
1. A: "I know how you are feeling" assumes the tutor knows the exact emotions of the patient, which can come off as insincere or dismissive.
2. B: "You have lived a long life" does not address the patient's emotional distress or provide comfort in the face of a terminal illness.
3. D: "Life can be so unfair" does not directly address the patient's feelings and may come off as generic or cliché.
The nurse should recognize the greatest risk for the development of blindness in which of the following patients?
- A. A 58-year-old Caucasian woman with macular degeneration
- B. A 28-year-old Caucasian man with astigmatism
- C. A 58-year-old African American woman with hyperopia
- D. A 28-year-old African American man with myopia
Correct Answer: A
Rationale: The correct answer is A because macular degeneration is a leading cause of blindness in older adults. The macula is responsible for central vision, crucial for tasks like reading and driving. Macular degeneration can lead to permanent vision loss if not managed promptly. The other choices are less likely to result in blindness: astigmatism, hyperopia, and myopia are refractive errors that can be corrected with glasses or contacts, and they do not typically lead to blindness. The age and condition of the patient are important factors in determining the risk of blindness.
A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.
- A. 1800
- B. 450
- C. 900
- D. 90
Correct Answer: C
Rationale: The correct answer is C (900 mL) because the weight of 900 g corresponds to a blood loss of the same amount in milliliters. Blood density is close to that of water, so 1 g ≈ 1 mL. Therefore, a blood-soaked peripad weighing 900 g indicates a blood loss of 900 mL. Choice A (1800 mL) is incorrect as it doubles the weight instead of converting it to milliliters. Choice B (450 mL) is incorrect as it halves the weight. Choice D (90 mL) is incorrect as it divides the weight by 10, which is too small for the blood loss indicated.
The organization of a patients care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice?
- A. It is based on the participation of clinicians without a team leader.
- B. It is based on clinicians of varied backgrounds integrating their separate plans of care.
- C. It is based on communication and cooperation between disciplines.
- D. It is based on medical expertise and patient preference with the support of nursing.
Correct Answer: B
Rationale: Interdisciplinary collaboration involves clinicians from different backgrounds integrating their separate plans of care, ensuring a holistic approach to patient care. This fosters a comprehensive understanding of the patient's needs and individualized care. In contrast, multidisciplinary practice involves clinicians working independently without integrating their plans, potentially leading to fragmented care.
Choice A is incorrect as interdisciplinary collaboration does have a team leader to coordinate and facilitate communication among team members.
Choice C is incorrect because while communication and cooperation are essential in interdisciplinary collaboration, the key distinction is the integration of different perspectives and plans of care.
Choice D is incorrect as interdisciplinary collaboration goes beyond just medical expertise and patient preference, involving professionals from various disciplines working together to address all aspects of patient care.
A nurse is sitting at the patient’s bedside takinga nursing history. Which zone of personal space is the nurse using?
- A. Socio-consultative
- B. Personal
- C. Intimate
- D. Public
Correct Answer: B
Rationale: The nurse sitting at the patient's bedside is using the personal zone of personal space, which ranges from 18 inches to 4 feet. This distance allows for a close interaction suitable for taking a nursing history while maintaining a professional yet personal connection. The socio-consultative zone (A) is 4-12 feet, more appropriate for professional interactions. The intimate zone (C) is 0-18 inches, too close for an initial nursing history. The public zone (D) is 12 feet or more, too distant for a personal conversation.