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A nurse is standing beside the patient’s bed. Nurse:How are you doing? Patient:I don’t feel good. Which element will the nurse identify as feedback?
- A. Nurse
- B. Patient
- C. How are you doing?
- D. I don’t feel good.
Correct Answer: D
Rationale: In communication, feedback is the response or message provided by the receiver to the sender. In this scenario, the nurse asks the patient, "How are you doing?" The patient's response, "I don't feel good," is the feedback. It is the patient's reaction and message returning to the nurse. The nurse, in this context, is the sender initiating the conversation, while the patient is the receiver providing the feedback in response to the nurse's inquiry. Therefore, the statement "I don't feel good" constitutes the feedback in this communication exchange.
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A nurse is assessing population groups for therisk of suicide requiring medical attention. Which group should the nurse monitormostclosely?
- A. Young bisexuals
- B. Young caucasians
- C. Asian Americans
- D. African-Americans.
Correct Answer: A
Rationale: Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide attempts, and substance use disorders. In particular, bisexual youth are at a higher risk than their straight peers for experiencing mental health issues and suicide attempts that require medical attention. Studies have shown that young bisexuals are four times more likely than their straight counterparts to make suicide attempts that necessitate medical intervention. Therefore, it is crucial for the nurse to closely monitor this population group for signs of suicidal behavior and provide the necessary support and interventions to prevent such tragedies.
A small-bore feeding tube is placed. Which technique will the nurse use tobestverify tube placement?
- A. X-ray
- B. pH testing
- C. Auscultation
- D. Aspiration of contents
Correct Answer: A
Rationale: At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray examination. X-ray allows for direct visualization of the tube's placement within the gastrointestinal tract, ensuring it is correctly positioned in the stomach without any risk of inadvertent placement in the lungs, pharynx, or esophagus. This method provides a definitive confirmation of tube placement, which is crucial for patient safety during enteral feeding. While pH testing and aspiration of contents can be useful as supplementary methods, x-ray remains the gold standard for verifying tube placement due to its precision and accuracy. Auscultation, on the other hand, is no longer recommended as a reliable method for tube placement verification, as it may lead to misinterpretation of sounds and potential errors in placement assessment.
While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?
- A. Stopping the administration of the drug immediately
- B. Notifying the patients physician
- C. Continuing the infusion but decreasing the rate
- D. Applying a warm compress to the infusion site .
Correct Answer: A
Rationale: Swelling and pain at the IV site can indicate extravasation, which is the leakage of a vesicant medication like doxorubicin hydrochloride into the surrounding tissues. It is crucial to stop the administration of the drug immediately upon suspicion of extravasation to minimize tissue damage and potential complications. By stopping the administration promptly, further harm can be prevented, and early interventions can be initiated to mitigate the effects of the extravasation. Notifications to the physician and appropriate actions, such as aspiration of any remaining drug, may follow after discontinuing the infusion.
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response?
- A. Do you think that you might already have HIV?
- B. Dont worry. Your immune system is likely very healthy.
- C. AIDS isnt transmitted by casual contact.
- D. You cant contract AIDS in a hospital setting.
Correct Answer: C
Rationale: The nurse's best response is option C - "AIDS isn't transmitted by casual contact." This response is accurate and provides the necessary information to address the friend's concern. It is important to educate the friend that HIV/AIDS is not transmitted through casual contact such as visiting a patient in the hospital. By stating this fact clearly, the nurse can help alleviate any unfounded fears or misconceptions the friend may have about contracting HIV while visiting the patient. This response promotes understanding and helps reduce stigma associated with HIV/AIDS, while also emphasizing the importance of accurate information in preventing the spread of the virus.
A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate?
- A. Holding the next dose and notifying the physician
- B. Treating the patient for an allergic reaction
- C. Suggesting that the patient put on her glasses
- D. Explaining that this is an expected adverse effect
Correct Answer: D
Rationale: Blurred vision is a common adverse effect of pilocarpine, a miotic agent commonly used for open-angle glaucoma. It occurs due to the constriction of the pupil, which can affect the patient's ability to focus clearly. Therefore, it is important for the nurse to explain to the patient that blurred vision is an expected adverse effect of the medication. This reassurance can help alleviate the patient's concerns and improve their understanding of the medication therapy. Holding the next dose and notifying the physician is not necessary in this situation as blurred vision is a known side effect and treating the patient for an allergic reaction or suggesting that the patient put on her glasses would not address the underlying cause of the blurred vision.