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A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using?
- A. Nonjudgmental
- B. Socializing
- C. Narrative
- D. SBAR
Correct Answer: C
Rationale: The correct answer is C: Narrative. The nurse is using a narrative interaction by asking the patient to share a personal story. This helps the patient express their experiences, emotions, and perspectives, promoting a deeper understanding of their care needs. A: Nonjudgmental is incorrect as it focuses on avoiding biases. B: Socializing is incorrect as it implies casual conversation. D: SBAR is incorrect as it stands for Situation, Background, Assessment, and Recommendation, used for concise communication in healthcare settings.
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Which data found on a patient’s health history would place her at risk for an ectopic pregnancy?
- A. Ovarian cyst 2 years ago
- B. Recurrent pelvic infections
- C. Use of oral contraceptives for 5 years
- D. Heavy menstrual flow of 4 days’ duration
Correct Answer: B
Rationale: The correct answer is B: Recurrent pelvic infections. Pelvic infections can lead to scarring and blockage of the fallopian tubes, increasing the risk of ectopic pregnancy. Ovarian cysts and oral contraceptives are not directly linked to ectopic pregnancies. Heavy menstrual flow does not inherently increase the risk of ectopic pregnancy.
A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurses initial intervention for this patient?
- A. Generously flush the affected eye with a dilute antibiotic solution.
- B. Generously flush the affected eye with normal saline or water.
- C. Apply a patch to the affected eye.
- D. Apply direct pressure to the affected eye.
Correct Answer: B
Rationale: The correct initial intervention for a chemical burn to the eye is to generously flush the affected eye with normal saline or water. Flushing helps to remove the chemical from the eye, preventing further damage. Antibiotic solution (choice A) is not the first intervention as the priority is to remove the chemical. Applying a patch (choice C) can trap the chemical against the eye, worsening the injury. Applying direct pressure (choice D) is not appropriate and can cause additional harm. Flushing with normal saline or water is the most effective and safest initial intervention to minimize damage from a chemical burn to the eye.
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
- A. From the tip of the nose to the earlobe
- B. From the tip of the earlobe to the xiphoid process
- C. From the tip of the earlobe to the nose to the xiphoid process
- D. From the tip of the nose to the earlobe to the xiphoid process
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement.
Summary of Incorrect Choices:
A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach.
B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage.
D: Measuring from the tip of the nose to the earlobe to
A nurse is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
- A. Administration of the measles-mumps-rubella (MMR) vaccine
- B. Rapid administration of intravenous fluids
- C. Computed tomography with contrast solution
- D. Administration of nebulized bronchodilators
Correct Answer: C
Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient.
Incorrect choices:
A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans.
B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis.
D: Administration of nebulized bronchodil
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
- A. 1+ protein in urine
- B. 2+ pitting edema in lower extremities
- C. Urine output >100 mL/hour
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Step 1: Increased urine output indicates improved kidney function, a key indicator of recovery from preeclampsia.
Step 2: Adequate urine output helps regulate blood pressure and reduce swelling.
Step 3: Consistent urine output >100 mL/hour signifies the kidneys are functioning properly.
Step 4: Therefore, C is the correct answer as it directly reflects recovery progress from preeclampsia.
Summary: A, B, and D are incorrect as they do not directly correlate with kidney function or recovery from preeclampsia.