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A nurse is teaching a health class about colorectalcancer. Which information should the nurse include in the teaching session? (Select all that apply.)
- A. A risk factor is smoking.
- B. A risk factor is high intake of animal fats or red meat.
- C. A warning sign is rectal bleeding.
- D. A warning sign is a sense of incomplete evacuation.
Correct Answer: A
Rationale: A. A risk factor is smoking: Smoking has been identified as a risk factor for colorectal cancer. It is important for the nurse to include this information during the teaching session to emphasize the importance of smoking cessation in reducing the risk of developing colorectal cancer.
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The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first time. What is the most significant challenge experienced by a patient with hearing loss who is adapting to using a hearing aid for the first time?
- A. Regulating the tone and volume
- B. Learning to cope with amplification of background noise
- C. Constant irritation of the external auditory canal
- D. Challenges in keeping the hearing aid clean while minimizing exposure to moisture
Correct Answer: B
Rationale: One of the most significant challenges experienced by patients with hearing loss who are adapting to using a hearing aid for the first time is learning to cope with the amplification of background noise. When a person starts using a hearing aid after experiencing hearing loss, they may find that the device picks up not only the sounds they want to hear but also surrounding noises, such as background chatter, traffic noise, or ambient sounds. This sudden increase in volume and clarity of background noise can be overwhelming and challenging for the individual to adjust to. It can affect their ability to focus on conversations or specific sounds they are trying to hear, leading to frustration and potentially causing them to avoid using the hearing aid altogether. Supporting the patient in gradually acclimating to these new sounds and providing strategies for managing background noise can help improve their overall experience with the hearing aid.
A nurse is providing care to a group of patients.Which situation will require the nurse to obtain a telephone order?
- A. As the nurse and health care provider leave a patient’s room, the primary care provider gives the nurse an order.
- B. At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.
- C. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order.
- D. A nurse reads an order correctly as written by the health care provider in the patient’s medical record
Correct Answer: B
Rationale: In this situation, the nurse needs to obtain a telephone order because the patient's condition has changed significantly. The drop in blood pressure from 120/80 to 90/50 along with the saturated incision dressing indicates a potential complication or need for immediate intervention. The nurse must act quickly to address the situation and may require additional orders from the primary care provider over the phone to manage the patient's condition effectively. The urgency and critical nature of the situation necessitate obtaining a telephone order promptly to ensure the best outcome for the patient.
A 60-year-old patient with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high-dose radiation (HDR). What safety measure should the nurse include in this patients subsequent plan of care?
- A. Limit the time that visitors spend at the patients bedside.
- B. Teach the patient to perform all aspects of basic care independently.
- C. Assign male nurses to the patients care whenever possible.
- D. Situate the patient in a shared room with other patients receiving brachytherapy.
Correct Answer: A
Rationale: The patient undergoing interstitial implant for high-dose radiation (HDR) for prostate cancer will emit radiation that poses a risk to others. Limiting the time that visitors spend at the patient's bedside is essential to minimize their exposure to radiation. It is important to follow safety measures to protect both the patient and others from potential harm. Other options such as teaching the patient to perform basic care independently, assigning male nurses, or situating the patient in a shared room with other brachytherapy patients do not directly address the safety concern of radiation exposure to visitors.
A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first?
- A. Perform oral suctioning.
- B. Page the physician.
- C. Insert a tongue depressor into the patients mouth.
- D. Turn the patient on his side.
Correct Answer: D
Rationale: When a patient is experiencing a seizure and begins vomiting, the priority action for the nurse is to turn the patient onto their side. This position helps to prevent aspiration, which can occur when the patient inhales vomit into their lungs. Turning the patient on their side allows for the vomit to drain out of the mouth, reducing the risk of aspiration and maintaining a clear airway. Performing oral suctioning would be necessary after turning the patient on their side, but it is not the initial priority in this situation. Paging the physician and inserting a tongue depressor are not appropriate actions during a seizure and vomiting episode.
A nurse is discussing the advantages of a nursingclinical information system. Which advantage should the nurse describe?
- A. Varied clinical databases
- B. Reduced errors of omission
- C. Increased hospital costs
- D. More time to read charts
Correct Answer: B
Rationale: One of the key advantages associated with a nursing clinical information system is the reduction of errors of omission. By using an electronic system that prompts for required data entry and ensures completeness of documentation, nurses are less likely to miss important information, leading to improved patient care and safety. This advantage helps in promoting efficient communication among healthcare providers and contributes to better decision-making processes.