Nokea
A nurse walks into a patients room and begins preparing a syringe to perform a blood draw on the patient. The nurse observes that the patient is firmly gripping the side of the bed, averting her eyes, and sweating from her forehead when she sees the needle. What would be the best intervention for the nurse to make?
- A. Proceed with blood draw as quickly as possible, to get it over with.
- B. Offer to come back later to perform the blood draw.
- C. Encourage the patient to deep breathe.
- D. Describe briefly the blood draw procedure and explain why it is necessary.
Correct Answer: D
Rationale: The correct answer is D because it shows empathy and promotes patient education. By describing the procedure and its necessity, the nurse can alleviate the patient's anxiety and build trust. This approach allows the patient to feel informed and in control, reducing fear and increasing cooperation. It also demonstrates respect for the patient's feelings and promotes a therapeutic relationship.
Choice A is incorrect as it disregards the patient's fear and can lead to increased distress. Choice B might be an option, but it doesn't address the patient's anxiety in the moment. Choice C, while helpful in some cases, doesn't directly address the patient's specific fear of the blood draw procedure.
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What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?
- A. Case management.
- B. Team nursing.
- C. Primary nursing.
- D. Functional nursing.
Correct Answer: C
Rationale: The correct answer is C: Primary nursing. Primary nursing is a care delivery model where one nurse is responsible for the total care of a group of clients over a 24-hour period. This promotes continuity of care, individualized attention, and better nurse-client relationships. In primary nursing, the nurse plans and directs care, coordinates with other healthcare team members, and serves as the main point of contact for the clients.
A: Case management involves coordinating care across different healthcare providers and services, not necessarily focusing on a specific group of clients over a 24-hour period.
B: Team nursing involves a team of healthcare providers working together to deliver care, rather than one nurse being responsible for a specific group of clients over a 24-hour period.
D: Functional nursing divides tasks among different healthcare team members based on their specific skills, which may not provide the same level of continuity and individualized care as primary nursing.
An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?
- A. Antacids.
- B. Tricyclic antidepressants.
- C. Nonsteroidal anti-inflammatory agents.
- D. Insulin.
Correct Answer: B
Rationale: The correct answer is B: Tricyclic antidepressants. Tricyclic antidepressants can cause anticholinergic effects, including urinary retention, especially in the elderly. Morphine sulfate can also contribute to urinary retention. Antacids (A) and nonsteroidal anti-inflammatory agents (C) are not known to cause urinary retention. Insulin (D) does not pose a risk for urinary retention in this scenario.
Nociceptors differ from other nerve receptors in the body in what way?
- A. They adapt very little to continual pain response.
- B. They inhibit the infiltration of neutrophils and eosinophils.
- C. They play no role in the inflammatory response.
- D. They transmit only the thermal stimuli.
Correct Answer: A
Rationale: The correct answer is A because nociceptors are specialized nerve receptors that do not adapt much to continual pain response. This lack of adaptation allows nociceptors to continuously signal the presence of tissue-damaging stimuli, which is crucial for the perception of pain. Choices B, C, and D are incorrect because nociceptors do not inhibit the infiltration of neutrophils and eosinophils (B), they do play a role in the inflammatory response (C), and they transmit various types of stimuli including thermal, mechanical, and chemical, not just thermal stimuli (D).
The nurse is assisting with endotracheal intubation and un derstands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.)
- A. Auscultation of air over the epigastrium
- B. Equal bilateral breath sounds upon auscultation
- C. Position above the carina verified by chest x-ray
- D. Positive detection of carbon dioxide (CO
Correct Answer: B
Rationale: The correct answer is B: Equal bilateral breath sounds upon auscultation. This indicates proper placement of the endotracheal tube in the trachea, ensuring both lungs are being ventilated equally.
Rationale:
1. Auscultation of air over the epigastrium (Choice A) is incorrect as it indicates esophageal intubation, not tracheal intubation.
2. Position above the carina verified by chest x-ray (Choice C) is incorrect as it does not confirm proper placement at the trachea.
3. Positive detection of carbon dioxide (CO2) (Choice D) is incorrect as it indicates the presence of exhaled CO2, but not necessarily proper placement in the trachea.
The client has been in the CCU for several weeks and has been very unstable. One family member stays at the bedside constantly and even naps in a bedside chair. The nurse understands that the family member is exhibiting which family member response to critical illness?
- A. Exhibiting extreme distrust of the health care team
- B. Seeking evidence for future legal or punitive action
- C. Trying to maintain a level of control over the situation
- D. Experiencing extreme fatigue from constant stress
Correct Answer: C
Rationale: The correct answer is C: Trying to maintain a level of control over the situation. The family member staying at the bedside constantly and even napping there is likely trying to cope with the stressful situation by maintaining a sense of control and connection to the patient. This behavior can be a way for the family member to feel more involved and helpful during a time of uncertainty and powerlessness. Choices A and B involve negative assumptions about the family member's intentions without evidence. Choice D may be a result of the family member's actions but does not address the underlying motivation for their behavior.