Nokea
A nurse is providing care to a patient from adifferent culture. Which action by the nurse indicates cultural competence?
- A. Communicates effectively in a multicultural context
- B. Functions effectively in a multicultural context
- C. Visits a foreign country
- D. Speaks a different language
Correct Answer: A
Rationale: The correct answer is A because effective communication in a multicultural context is essential for cultural competence. By communicating effectively, the nurse can understand and respect the patient's cultural beliefs, values, and practices. This helps in providing appropriate care tailored to the patient's cultural needs. Choice B is too vague and does not specifically address communication skills. Choice C, visiting a foreign country, does not directly demonstrate cultural competence in patient care. Choice D, speaking a different language, is important but not sufficient on its own to indicate cultural competence without effective communication skills.
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An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patients plan of nursing care should prioritize which of the following?
- A. Assess the patient hourly for signs of compartment syndrome.
- B. Assess the patients fine motor skills once per shift.
- C. Assess the patients wound for dehiscence every 4 hours.
- D. Maintain the patients head of bed at 45 degrees or more at all times.
Correct Answer: C
Rationale: The correct answer is C because assessing the patient's wound for dehiscence every 4 hours is crucial post hemicolectomy to monitor for any signs of wound complications, such as infection or tissue breakdown. This allows for early detection and intervention, promoting optimal wound healing and preventing potential complications.
Choice A is incorrect as compartment syndrome is not a common complication after a hemicolectomy, and assessing for it hourly would be excessive and unnecessary.
Choice B is incorrect as assessing fine motor skills is not a priority in the immediate postoperative period following a hemicolectomy.
Choice D is incorrect as maintaining the patient's head of bed at 45 degrees or more is important for preventing respiratory complications, but it is not the top priority compared to wound assessment for dehiscence in this scenario.
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
- A. 1+ protein in urine
- B. 2+ pitting edema in lower extremities
- C. Urine output >100 mL/hour
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Step 1: Increased urine output indicates improved kidney function, a key indicator of recovery from preeclampsia.
Step 2: Adequate urine output helps regulate blood pressure and reduce swelling.
Step 3: Consistent urine output >100 mL/hour signifies the kidneys are functioning properly.
Step 4: Therefore, C is the correct answer as it directly reflects recovery progress from preeclampsia.
Summary: A, B, and D are incorrect as they do not directly correlate with kidney function or recovery from preeclampsia.
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?
- A. An incisional biopsy is performed because its known to be less painful and more accurate than other forms of testing.
- B. An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment.
- C. An incisional biopsy is performed to assess the potential for recovery from a mastectomy.
- D. An incisional biopsy is performed on patients who are younger than the age of 40 and who are otherwise healthy.
Correct Answer: B
Rationale: The correct answer is B because an incisional biopsy is typically performed to confirm a diagnosis by obtaining a sample of the tissue in question. This allows for further analysis through special studies to determine the best course of treatment. The other choices are incorrect because:
A: The reason for performing an incisional biopsy is not primarily based on pain or accuracy comparisons with other testing methods.
C: An incisional biopsy is not done to assess potential recovery from a mastectomy but rather to diagnose the nature of the mass.
D: Age and general health status are not sole criteria for determining the need for an incisional biopsy.
An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication?
- A. The patient who is oriented, pain free, and blind
- B. The patient who is alert, hungry, and has strong self-esteem
- C. The patient who is cooperative, depressed, and hard of hearing
- D. The patient who is dyspneic, anxious, and has a tracheostomy Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, tracheostomy, and anxiety all contribute to communication concerns. appropriate to facilitate communication?
Correct Answer: D
Rationale: The correct answer is D because a dyspneic patient with a tracheostomy may have difficulty speaking due to impaired airflow and mobility of the tongue. In this case, using alternative communication methods such as writing or using communication boards would be more effective.
Choice A is incorrect because being blind does not directly impact communication in this scenario. Choice B is incorrect as hunger, alertness, and self-esteem do not relate to the communication challenges presented. Choice C is incorrect as depression, while important to consider, is not the primary factor impacting communication in this case.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is N R I G B.C M U S N T O based on which of the following?
- A. Hemorrhage is the primary concern.
- B. She will be unable to conceive in the future.
- C. Bed rest and analgesics are the recommended treatment.
- D. A D&C will be performed to remove the products of conception.
Correct Answer: A
Rationale: The correct answer is A because hemorrhage is the primary concern in ectopic pregnancy due to the risk of rupture and severe bleeding. Immediate intervention is crucial to prevent life-threatening complications.
Choice B is incorrect as future fertility may be affected but is not the immediate concern. Choice C is incorrect as bed rest and analgesics are not effective treatments for ectopic pregnancy. Choice D is incorrect as a D&C is not performed in ectopic pregnancy; surgical intervention is required to remove the ectopic pregnancy.