Nokea
A patient expresses concerns over having blackstool. The fecal occult test is negative. Which response by the nurse is mostappropriate?
- A. “This is probably a false negative; we should rerun the test.”
- B. “You should schedule a colonoscopy as soon as possible.”
- C. “Are you under a lot of stress?”
- D. “Do you take iron supplements?”
Correct Answer: D
Rationale: Black or tarry stools can be caused by certain medications and supplements, such as iron supplements. Since the fecal occult test is negative, it indicates that bleeding is not occurring. Therefore, in this situation, it is important to consider factors that can affect the color of stool, including iron supplementation. Addressing this question can help determine the cause of the black stool and provide appropriate guidance or reassurance to the patient. This response shows a comprehensive understanding of potential causes and demonstrates a thoughtful approach in addressing the patient's concern.
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For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to
- A. 6:30 AM on January 13
- B. 6:30 PM on January 13
- C. 6:30 PM on January 14
- D. 6:30 AM on January 15
Correct Answer: A
Rationale: Rho(D) immune globulin (RhoGAM) needs to be administered within 72 hours postpartum to Rh-negative patients who have given birth to Rh-positive infants to prevent Rh sensitization. The patient delivered at 6:30 AM on January 10, so the RhoGAM should be administered prior to that time on January 13, which is 72 hours postpartum. Therefore, the correct choice is A. 6:30 AM on January 10.
A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action?
- A. To promote autonomy
- B. To use common courtesy
- C. To establish trustworthiness
- D. To standardize communication
Correct Answer: D
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.
A patients rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patients care, the nurse should identify what primary aim?
- A. To prioritize emotional needs
- B. To prevent and relieve suffering
- C. To bridge between curative care and hospice care
- D. To provide care while there is still hope
Correct Answer: B
Rationale: The primary aim when transitioning a patient with rapid cancer metastases from active treatment to palliative care is to prevent and relieve suffering. Palliative care focuses on enhancing quality of life, managing symptoms, and addressing physical, emotional, and spiritual needs. By prioritizing the prevention and relief of suffering, healthcare providers can work towards improving the patient's comfort and overall well-being during this difficult time. This approach aligns with the goals of palliative care, which aim to provide holistic support and care for patients facing serious illnesses like cancer.
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 patient has presented at the clinic with symptoms of benign prostatic hyperplasia. What diagnostic findings would suggest that this patient has chronic urinary retention?
- A. Hypertension
- B. Peripheral edema
- C. Tachycardia and other dysrhythmias
- D. Increased blood urea nitrogen (BUN)
Correct Answer: D
Rationale: Chronic urinary retention can lead to an elevated blood urea nitrogen (BUN) level due to impaired kidney function. When urine is not effectively eliminated from the body, waste products, including urea, accumulate in the bloodstream. This can result in an increase in BUN levels, indicating potential kidney dysfunction in the setting of chronic urinary retention. Hypertension (Choice A), peripheral edema (Choice B), and tachycardia and other dysrhythmias (Choice C) are not specifically associated with chronic urinary retention but may be related to other conditions or comorbidities.