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A nurse is preparing to perform a chest tube insertion for a patient with a pneumothorax. What action should the nurse prioritize to ensure proper placement of the chest tube?
- A. Positioning the patient in a semi-Fowler's position with arms elevated
- B. Marking the insertion site with a pen to guide tube placement
- C. Administering analgesia to the patient before the procedure
- D. Confirming the insertion site and direction using imaging guidance
Correct Answer: D
Rationale: The correct answer is D because confirming the insertion site and direction using imaging guidance ensures precise placement of the chest tube, minimizing the risk of complications. Imaging guidance allows the nurse to visualize the exact location of the pneumothorax and guide the tube insertion accurately.
A: Positioning the patient in a semi-Fowler's position with arms elevated may be beneficial for comfort but does not directly ensure proper chest tube placement.
B: Marking the insertion site with a pen may help as a reference point but does not guarantee accurate placement.
C: Administering analgesia is important for the patient's comfort but does not impact the placement of the chest tube.
In summary, choice D is the most critical step to ensure the chest tube is correctly placed and effectively treats the pneumothorax.
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Ms. Nena is specifically assigned to talk individually with community leaders like the primary grade teacher and the barangay official in charge of the health committee. Which data collection method will the nurse use?
- A. Key informant interview
- B. Participant observer
- C. Community mapping
- D. Social survey
Correct Answer: A
Rationale: The correct answer is A: Key informant interview. Ms. Nena will use this method to gather in-depth information from knowledgeable individuals within the community. This approach allows her to gain insights and perspectives from key stakeholders, such as the primary grade teacher and barangay official, who have first-hand knowledge and experience. Key informant interviews are particularly useful for obtaining specific details, opinions, and insights that may not be easily accessible through other methods. In contrast, participant observer involves direct participation in community activities, community mapping focuses on spatial data collection, and social survey typically involves collecting data from a larger sample size rather than individual key informants.
During a surgical procedure, the nurse notices a sudden decrease in the patient's oxygen saturation on the monitor. What immediate action should the nurse take?
- A. Inform the surgeon and anesthesiologist
- B. Increase the flow rate of oxygen
- C. Check the endotracheal tube placement
- D. Assess the patient's respiratory status
Correct Answer: A
Rationale: The correct immediate action is to inform the surgeon and anesthesiologist (Choice A) because a sudden decrease in oxygen saturation during surgery is a critical situation that requires prompt attention from the entire surgical team. The surgeon and anesthesiologist need to be made aware of the situation so that they can assess the patient's condition and make any necessary adjustments to the surgical procedure or anesthesia delivery. Increasing the flow rate of oxygen (Choice B) may help temporarily but does not address the underlying cause of the oxygen desaturation. Checking the endotracheal tube placement (Choice C) is important but may not be the immediate priority in this critical situation. Assessing the patient's respiratory status (Choice D) is important but should be done after informing the surgeon and anesthesiologist to ensure coordinated and timely interventions.
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.
The PRIORITY nursing objective when caring a patient with a tracheostomy is _________.
- A. To increase tissue oxygenation
- B. To provide patent airway
- C. To decrease tissue oxygenation
- D. To improve ventilation
Correct Answer: B
Rationale: The correct answer is B: To provide a patent airway. When caring for a patient with a tracheostomy, ensuring a clear and unobstructed airway is the top priority to maintain adequate oxygenation and ventilation. This involves suctioning, maintaining proper tube placement, and monitoring for any signs of respiratory distress. Choices A, C, and D are incorrect as they do not address the immediate need for airway management, which is crucial for the patient's safety and well-being.
To assist them enhance their performance at work, the nurse manager should review regularly pertaining to the staff's
- A. Number of submitted incident report
- B. Academic performance in college
- C. Job description
- D. Family dynamics
Correct Answer: C
Rationale: Step 1: Job description is crucial for clarifying roles and responsibilities, ensuring staff understand their duties.
Step 2: Regular review of job descriptions helps align staff performance with organizational goals and expectations.
Step 3: It allows for identifying areas of improvement and providing necessary support and resources.
Step 4: Academic performance in college, family dynamics, and number of incident reports are not directly related to work performance.
Summary: Regularly reviewing staff job descriptions is essential for enhancing performance by clarifying roles, aligning expectations, and identifying areas for improvement. Other choices lack direct relevance to work performance.