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A nurse obtained a telephone order from a primarycare provider for a patient in pain. Which chart entry should the nurse document?
- A. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
- B. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back.
- C. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
- D. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN.
Correct Answer: C
Rationale: The correct answer is C because it includes all necessary components for a complete and accurate chart entry. The nurse documents the date and time of the order, the medication prescribed (Morphine, 2 mg, IV every 4 hours), the indication for use (incisional pain), the intended recipient (Dr. Day), the nurse's name (J. Winds), and confirmation of the read-back procedure. This entry ensures clarity, accountability, and proper communication among healthcare team members.
Choice A is incorrect because it misses the recipient of the order (Dr. Day) and only includes the nurse's name in the read-back. Choice B is incorrect because it lacks the recipient of the order and the confirmation of the read-back procedure with the primary care provider. Choice D is incorrect because it does not specify the primary care provider who gave the order and misses the read-back confirmation with the provider.
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A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care?
- A. Assessing for mouth droop and decreased lateral eye gaze
- B. Assessing for increased middle ear pressure and perforated ear drum
- C. Assessing for gradual onset of conductive hearing loss and nystagmus
- D. Assessing for scar tissue and cerumen obstructing the auditory canal
Correct Answer: A
Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications.
Choices B, C, and D are incorrect:
B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient.
C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively.
D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.
The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination?
- A. Use of a bedpan
- B. Use of a raised toilet seat
- C. Sitting quietly on the toilet every 2 hours
- D. Following the outlined bowel program
Correct Answer: B
Rationale: Correct Answer: B - Use of a raised toilet seat
Rationale: A raised toilet seat helps the patient with Parkinson's disease by providing additional height, making it easier for them to transition from sitting to standing. This aids in improving mobility and reducing the risk of falls. Furthermore, the raised seat can also promote proper positioning for bowel elimination, making the process more comfortable and effective.
Incorrect Choices:
A: Using a bedpan does not address the issue of transitioning from sitting to standing, nor does it aid in improving bowel elimination for the patient.
C: Sitting quietly on the toilet every 2 hours may not directly address the physical challenges the patient is facing in transitioning from sitting to standing.
D: Following the outlined bowel program is important, but it does not specifically address the physical support needed to transition from sitting to standing for a patient with Parkinson's disease.
A student nurse is doing clinical hours at an OB/GYN clinic. The student is helping to develop a plan of care for a patient with gonorrhea who has presented at the clinic. The student should include which of the following in the care plan for this patient?
- A. The patient may benefit from oral contraceptives.
- B. The patient must avoid use of tampons.
- C. The patient is susceptible to urinary incontinence.
- D. The patient should also be treated for chlamydia.
Correct Answer: D
Rationale: Correct Answer: D - The patient should also be treated for chlamydia.
Rationale:
1. Gonorrhea and chlamydia often coexist, so it is crucial to treat both infections to prevent complications.
2. Treating only gonorrhea may not fully resolve the patient's symptoms or prevent reinfection.
3. Dual therapy for gonorrhea and chlamydia is recommended to ensure optimal care for the patient.
Summary of Incorrect Choices:
A: The patient may benefit from oral contraceptives - This is not directly related to the treatment of gonorrhea.
B: The patient must avoid use of tampons - This is not a standard recommendation for managing gonorrhea.
C: The patient is susceptible to urinary incontinence - This is not a typical complication of gonorrhea.
A patient has just been diagnosed with breast cancer and the nurse is performing a patient interview. In assessing this patients ability to cope with this diagnosis, what would be an appropriate question for the nurse to ask this patient?
- A. What is your level of education?
- B. Are you feeling alright these days?
- C. Is there someone you trust to help you make treatment choices?
- D. Are you concerned about receiving this diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Is there someone you trust to help you make treatment choices? This question assesses the patient's support system and ability to make informed decisions, which are crucial in coping with a breast cancer diagnosis. It shows the nurse's consideration for the patient's emotional well-being and involvement in the decision-making process.
Choice A: What is your level of education? This question is not directly related to coping with the diagnosis of breast cancer and may not provide relevant information about the patient's ability to cope.
Choice B: Are you feeling alright these days? While this question shows concern for the patient's well-being, it does not specifically address coping mechanisms or support systems.
Choice D: Are you concerned about receiving this diagnosis? This question focuses on the patient's emotional reaction to the diagnosis but does not directly assess coping strategies or support systems.
A nurse is teaching a patient about proteins that must be obtained through the diet and cannot be synthesized in the body. Which term used by the patient indicates teaching is successful?
- A. Amino acids
- B. Triglycerides
- C. Dispensable amino acids
- D. Indispensable amino acids
Correct Answer: D
Rationale: Rationale:
1. Indispensable amino acids, also known as essential amino acids, must be obtained through the diet as the body cannot synthesize them.
2. Amino acids are the building blocks of proteins, so mentioning "indispensable amino acids" indicates understanding of essential dietary proteins.
3. Triglycerides are fats, not proteins, and not related to essential amino acids.
4. Dispensable amino acids can be synthesized by the body, so mentioning them would not indicate understanding of essential proteins.