Nokea
A patient is irritable and complains to the nurse about difficulty sleeping last night. Which response by the nurse is most appropriate?
- A. "I know you will sleep better tonight.=
- B. "Tell me more about what happened last night.=
- C. "Did you drink too much caffeine yesterday?=
- D. "No one sleeps well in the hospital.=
Correct Answer: B
Rationale: The correct response is B. Asking the patient to elaborate on what happened last night allows the nurse to gather more information about the situation, which is crucial for assessing the patient's sleep difficulties accurately. It shows active listening and empathy, building rapport and trust with the patient. Options A, C, and D are incorrect because they do not address the patient's concerns effectively or gather relevant information to provide appropriate care. Option A makes an assumption without understanding the root cause of the sleep issue. Option C assumes the cause of sleep difficulty without exploring further. Option D dismisses the patient's concerns without providing support or understanding.
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The nurse is reviewing Mr. N's (non-Hodgkin lymphoma) medication administration record and sees that the combination therapy aprepitant, dexamethasone, and ondansetron was administered during the last shift. What is the nurse most likely to ask to determine efficacy of the therapy?
- A. "On a scale of 1 to 10, with 1 being the least and 10 being the worst, what number is your pain? Where is the pain located?"
- B. "Have the medications improved your appetite? Are there special foods that you would prefer?"
- C. "Are you having any feelings of nausea right now? When was the last time you vomited?"
- D. "After taking the medications, have you experienced any improvement in your energy level? Do you feel fatigued?"
Correct Answer: C
Rationale: The correct answer is C. The nurse would ask about feelings of nausea and vomiting to determine the efficacy of the antiemetic therapy. Nausea and vomiting are common side effects of chemotherapy, which Mr. N would receive for non-Hodgkin lymphoma. Improvement in these symptoms indicates the effectiveness of the antiemetic regimen. Choices A, B, and D are not directly related to the medications administered and would not provide valuable information on the efficacy of the therapy for managing chemotherapy-induced nausea and vomiting. Option A focuses on pain assessment, B on appetite and food preferences, and D on energy levels and fatigue, which are not the primary outcomes to evaluate in this context.
The nurse cares for a patient with a terminal illness. Which way would be the most therapeutic for the nurse to communicate with this patient?
- A. Use an honest, judgmental attitude.
- B. Demonstrate understanding with empathy.
- C. Acknowledge hope by expressions of sympathy.
- D. Consistently evaluate the patient's feelings.
Correct Answer: B
Rationale: The correct answer is B: Demonstrate understanding with empathy. This approach is the most therapeutic as it shows the nurse's genuine care and support for the patient, fostering a sense of trust and emotional connection. By empathizing, the nurse validates the patient's feelings and provides comfort without judgment.
A: Using an honest, judgmental attitude can be harmful and create a barrier in the nurse-patient relationship.
C: Acknowledging hope by expressions of sympathy is important but may not address the patient's immediate emotional needs.
D: Consistently evaluating the patient's feelings is important, but without demonstrating empathy, it may come across as clinical and detached.
In summary, choice B is the best approach as it prioritizes empathy and understanding, essential components in providing effective therapeutic communication.
The nurse observes a nursing assistant interacting with an elderly patient. Which statement by the nursing assistant requires an immediate intervention by the nurse?
- A. "I will help you remember where your room is located."
- B. "Would you like me to read from your Bible today?"
- C. "Tell me a story about when you were young."
- D. "Sweetie, I will bring your coffee in a few minutes."
Correct Answer: D
Rationale: The correct answer is D because addressing an elderly patient as "Sweetie" is inappropriate and unprofessional. It can be perceived as demeaning and disrespectful. The nurse should intervene immediately to address this issue. Choices A, B, and C are all appropriate ways to interact with an elderly patient and promote their well-being. Choice A shows willingness to assist with orientation, choice B offers emotional support through spiritual means, and choice C encourages reminiscence therapy, which can be beneficial for cognitive function.
When communicating with a hearing impaired patient, the nurse appropriately:
- A. shouts repeatedly at the patient.
- B. speaks directly into the patient's ear.
- C. uses long, complex sentences.
- D. uses short, simple sentences.
Correct Answer: D
Rationale: The correct answer is D: uses short, simple sentences. This is the most appropriate approach because hearing-impaired patients may have difficulty processing complex information. Using short, simple sentences helps improve comprehension. Shouting repeatedly (choice A) can be distressing and ineffective. Speaking directly into the patient's ear (choice B) may be invasive and uncomfortable. Using long, complex sentences (choice C) can overwhelm the patient and lead to confusion. Therefore, option D is the best choice for effective communication with a hearing-impaired patient.
Mr. L (tracheostomy and partial laryngectomy) needs to receive a dose of IV chemotherapy during the shift. What is the most important action to take to prevent extravasation?
- A. Carefully monitor the access site during the administration of the medication.
- B. Hold the medication until an implanted port or central line is established.
- C. Ensure that a chemotherapy-certified nurse is assigned to care for the client.
- D. Call the pharmacy to find out if the prescribed medication has vesicant properties.
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer, A:
1. Monitoring the access site during administration allows for early detection of extravasation.
2. Early detection can prevent serious tissue damage and complications.
3. As Mr. L has a tracheostomy and partial laryngectomy, his airway is compromised, making prevention of extravasation crucial.
4. This action is within the nurse's scope of practice and promotes patient safety.
Summary:
- Choice B is incorrect as delaying treatment can impact Mr. L's health.
- Choice C is not directly related to preventing extravasation.
- Choice D, though important, does not directly address preventing extravasation during administration.