Nokea
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan.
Now, let's analyze the other choices:
A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.
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A client asks the nurse what PSA is. The nurse should reply that is stands for:
- A. Prostate-specific antigen, which is used to screen for prostate cancer
- B. Protein serum antigen, which is used to determine protein levels
- C. Pneumococcal strep antigen, which is bacteria that causes pneumonia
- D. Papanicolua-specific antigen, which is used to screen for cervical cancer
Correct Answer: A
Rationale: The correct answer is A: Prostate-specific antigen, which is used to screen for prostate cancer. PSA is a protein produced by the prostate gland, and elevated levels may indicate prostate cancer. Choice B is incorrect as PSA is specific to the prostate, not protein levels. Choice C is incorrect as pneumococcal strep antigen is related to pneumonia, not PSA. Choice D is incorrect as Papanicolua-specific antigen is not a recognized term, and PSA is not used to screen for cervical cancer.
Which finding will alert the nurse that the goal has been met?
- A. Heart rate 78 beats/min on 12/3
- B. Heart rate 78 beats/min on 12/4
- C. Heart rate 80 beats/min on 12/3
- D. Heart rate 80 beats/min on 12/4
Correct Answer: A
Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.
A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?
- A. The nurse should practice interviewing strategies.
- B. The nurse should modify the data collection tool.
- C. The nurse should determine specific purpose of data collection.
- D. The nurse should update the database.
Correct Answer: A
Rationale: The correct answer is A: The nurse should practice interviewing strategies. This is the best remedy because improving the nurse's ability to gather comprehensive information during client history will ensure sufficient data for planning interventions. By practicing interviewing strategies, the nurse can learn to ask relevant questions, actively listen, and probe for additional details.
Summary:
B: Modifying the data collection tool may not address the issue of insufficient information if the problem lies with how the nurse conducts the interview.
C: Determining the specific purpose of data collection is important but may not solve the immediate issue of lacking information for intervention planning.
D: Updating the database is irrelevant to the problem of inadequate data collection during client history.
In the operating room, personnel should be responsible for ensuring cleanliness, proper temperature, humidity, and lighting. Who carries those responsibilities?
- A. circulating nurse
- B. scrub nurse
- C. surgeon
- D. anesthesiologist
Correct Answer: A
Rationale: The correct answer is A: circulating nurse. The circulating nurse is responsible for maintaining cleanliness, ensuring proper temperature, humidity, and lighting in the operating room. They coordinate activities, manage supplies, and ensure a safe environment for the surgical team. The scrub nurse assists the surgeon with instruments and supplies, not environmental conditions. The surgeon's main focus is on performing the surgery, not environmental management. The anesthesiologist is responsible for administering anesthesia and monitoring the patient's vital signs, not the operating room environment.
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
- A. Level of central vision
- B. Pupil responses
- C. External eye appearance
- D. Eye movements
Correct Answer: B
Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health.
A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment.
C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses.
D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.