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A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do?
- A. Call the physician and ask for the order to be confirmed.
- B. Follow the order because this position will help keep the retinal repair intact.
- C. Instruct the patient to maintain this position to prevent bleeding.
- D. Reposition the patient after the first dressing change.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Prone position post retinal detachment repair helps the gas bubble or silicone oil stay against the retina to support healing.
2. This position prevents the bubble/oil from moving and causing further detachment.
3. Repositioning can jeopardize the surgical repair and lead to complications.
4. Calling the physician (A) is unnecessary as the order is clear.
5. Instructing the patient to prevent bleeding (C) is not related to the positioning after retinal detachment repair.
6. Repositioning after the first dressing change (D) contradicts the initial order and risks complications.
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Which behaviors indicate the nurse is using criticalthinking standards when communicating with patients? (Select all that apply.)
- A. Instills faith
- B. Uses humility
- C. Portrays self-confidence
- D. Exhibits supportiveness
Correct Answer: B
Rationale: The correct answer is B: Uses humility. Critical thinking in nursing involves being open-minded, self-aware, and willing to consider different perspectives. Humility allows nurses to acknowledge their limitations, seek feedback, and continuously learn and improve. Instilling faith (A) may be important but does not directly relate to critical thinking standards. Self-confidence (C) can be beneficial, but excessive confidence can lead to closed-mindedness. Supportiveness (D) is valuable in patient care but does not specifically demonstrate critical thinking standards. In summary, humility enables nurses to approach patient communication with an open and reflective mindset, essential for applying critical thinking standards effectively.
A nurse is using therapeutic communication witha patient. Which technique will the nurse use to ensure effective communication?
- A. Interpersonal communication to change negative self-talk to positive self-talk
- B. Small group communication to present information to an audience
- C. Electronic communication to assess a patient in another city
- D. Intrapersonal communication to build strong teams
Correct Answer: A
Rationale: The correct answer is A because therapeutic communication focuses on building a trusting relationship and understanding the patient's feelings and needs. By changing negative self-talk to positive self-talk, the nurse can help the patient develop a more positive outlook and improve self-esteem. This technique promotes effective communication by creating a supportive and non-judgmental environment.
Option B is incorrect because small group communication is not the primary focus of therapeutic communication. Option C is incorrect as electronic communication lacks the personal interaction needed for therapeutic communication. Option D is incorrect because intrapersonal communication involves self-reflection and is not directly related to building strong teams in the context of patient care.
A patient has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation system in place. The patient tells you he is experiencing bladder spasms and asks what you can do to relieve his discomfort. What is the most appropriate nursing action to relieve the discomfort of the patient?
- A. Apply a cold compress to the pubic area.
- B. Notify the urologist promptly.
- C. Irrigate the catheter with 30 to 50 mL of normal saline as ordered.
- D. Administer a smooth-muscle relaxant as ordered.
Correct Answer: D
Rationale: Rationale: Administering a smooth-muscle relaxant is the most appropriate nursing action to relieve bladder spasms post-TURP. The smooth-muscle relaxant helps relax the bladder muscles, reducing spasms and discomfort. Applying a cold compress (choice A) may provide temporary relief but won't address the underlying cause. Notifying the urologist (choice B) is important but not the immediate action for relieving spasms. Irrigating the catheter with normal saline (choice C) may not effectively address the spasms. Administering a smooth-muscle relaxant is the best choice for prompt relief.
A nurse is caring for an 87-year-old Mexican-American female patient who is in end-stage renal disease. The physician has just been in to see the patient and her family to tell them that nothing more can be done for the patient and that death is not far. The physician offers to discharge the patient home to hospice care, but the patient and family refuse. After the physician leaves, the patients daughter approaches you and asks what hospice care is. What would this lack of knowledge about hospice care be perceived as?
- A. Lack of an American education of the patient and her family
- B. A language barrier to hospice care for this patient
- C. A barrier to hospice care for this patient
- D. Inability to grasp American concepts of health care
Correct Answer: C
Rationale: The correct answer is C: A barrier to hospice care for this patient. The lack of knowledge about hospice care can be perceived as a barrier to accessing this type of care for the patient and her family. Understanding hospice care is crucial in making informed decisions about end-of-life care options. This lack of knowledge does not necessarily indicate lack of education (choice A), language barrier (choice B), or inability to grasp American concepts of health care (choice D), as hospice care is a universal concept that transcends cultural and educational backgrounds.
The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patients plan of care?
- A. The nurse should perform the Rinne and Weber tests.
- B. The nurse should arrange for audiometry testing as soon as possible.
- C. The nurse should collaborate with the pharmacist to assess for potential ototoxic medications.
- D. No specific assessments or interventions are necessary to addressing exostoses.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Exostoses are bony growths in the external auditory canal.
2. These growths can cause narrowing and obstruction of the canal, affecting hearing.
3. Collaborating with the pharmacist to assess for ototoxic medications is crucial to prevent further hearing impairment.
4. Performing Rinne and Weber tests (choice A) and arranging audiometry testing (choice B) are not directly related to exostoses.
5. Ignoring exostoses (choice D) can lead to worsening hearing loss and potential complications.