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A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
- A. Individualize the care plan only according to the patient’s needs.
- B. Request that the son leave at bedtime, so the patient can rest.
- C. Suggest that a female member of the family stay with the patient.
- D. Involve the son in the plan of care as much as possible.
Correct Answer: D
Rationale: The correct answer is D: Involve the son in the plan of care as much as possible. This is important for several reasons. Firstly, involving the son promotes family-centered care, which can improve patient outcomes. Secondly, the son may provide valuable insights into the patient's preferences and needs. Thirdly, it can help reduce the patient's confusion by providing familiar support. Option A is incorrect as it disregards the potential benefits of involving family members. Option B is incorrect as it focuses on the patient's rest without considering the emotional support the son may provide. Option C is incorrect as it assumes the gender of the family member matters more than their relationship to the patient.
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An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: C
Rationale: Upon arrival, checking the lungs for equal breath sounds bilaterally is the first action. This is crucial to assess airway patency and breathing effectiveness in a patient with a history of diving accident and intubation. Ensuring proper oxygenation takes precedence over other actions. Taking vital signs, inserting an IV line, and performing a neurologic check can wait until airway and breathing are adequately assessed.
The nurse recognizes that the major early problem for Mr. Gabatan will be:
- A. Bladder control
- B. Quadriceps setting
- C. Client education
- D. Use of aids for ambulation
Correct Answer: B
Rationale: The correct answer is B: Quadriceps setting. After surgery, quadriceps setting exercises are crucial for preventing muscle atrophy and maintaining joint mobility. Bladder control (A) is important but typically not the major early problem. Client education (C) and use of aids for ambulation (D) are important aspects of care but not the primary concern immediately post-surgery. Quadriceps setting helps prevent complications and promote early mobility.
Wilma knew that the maximum time when suctioning James is
- A. 10 seconds
- B. 20 seconds
- C. 30 seconds
- D. 45 seconds SITUATION: A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Correct Answer: C
Rationale: The correct answer is C (30 seconds) because the maximum recommended time for suctioning a patient is typically around 10-15 seconds for each pass. Prolonged suctioning can lead to tissue damage, hypoxia, and increased risk of infection. In this case, given the patient's symptoms and medical history (vomiting, weight loss, dehydration, hypotension), it is crucial to limit suction time to prevent further complications. Choices A, B, and D are incorrect as they exceed the safe duration for suctioning and increase the risk of harm to the patient. Choice D, in particular, is significantly longer than the recommended time and could pose serious risks to the patient's health in this situation.
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B, "What reasons do you think are contributing to your fatigue?" This question encourages the patient to explore and express their own thoughts and feelings, leading to a more detailed and comprehensive understanding of the underlying causes of their daytime fatigue.
A: "Is there anything that you are stressed about right now that I should know?" - This question is more direct and may not necessarily prompt the patient to delve into the specific reasons for their fatigue.
C: "What are your normal work hours?" - While relevant, this question focuses solely on work hours and may not uncover other potential factors contributing to the fatigue.
D: "Are you sleeping 8 hours a night?" - While sleep is important, this question is too narrow and may not address other possible reasons for the fatigue.
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In the scenario, the nurse failed to assess the patient's condition promptly after the patient complained of feeling dizzy and light-headed. Assessment is the first phase of the nursing process and involves collecting data to identify the patient's health status. By not reassessing the patient's vital signs and symptoms, the nurse missed an opportunity to detect the worsening condition. The other choices are incorrect because the error occurred before diagnosis (B), implementation (C), and evaluation (D) phases. In diagnosis, the nurse identifies the patient's problems; in implementation, the nurse carries out the care plan; and in evaluation, the nurse assesses the effectiveness of interventions.