Nokea
A preceptor is working with a new nurse on documentation.Which situation will cause the preceptor to follow up?
- A. The new nurse documents only for self.
- B. The new nurse charts consecutively on every other line.
- C. The new nurse ends each entry with signature and title.
- D. The new nurse keeps the password secure.
Correct Answer: B
Rationale: The preceptor would need to follow up with the new nurse for charting consecutively on every other line. This behavior is incorrect as it can lead to confusion and potential errors in documentation. Correct charting practice involves documenting consecutively, line by line without skipping lines in between. The preceptor should provide guidance and correction to ensure accurate and organized documentation for patient care.
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The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
- A. Cool, clammy skin
- B. Altered sensorium
- C. Pulse oximeter reading of 95%
- D. Respiratory rate of less than 12 breaths per minute
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)
- A. Keeping the urine collection container on ice when indicated
- B. Withholding all patient medications for the day
- C. Irrigating the sample as needed with sterile solution
- D. Testing the urine sample with a reagent strip by dipping it in the urine
Correct Answer: A
Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.
To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select allthat apply.)
- A. Allows fasting on Yom Kippur for a Jewish patient
- B. Allows caffeine drinks for a Mormon patient
- C. Serves no ham products to a Muslim patient
- D. Serves kosher foods to a Christian patient
Correct Answer: A
Rationale: A. Allowing fasting on Yom Kippur for a Jewish patient demonstrates culturally sensitive care by respecting and accommodating the religious practices of the patient. Yom Kippur is an important day of fasting and repentance in the Jewish faith, and by allowing the patient to observe this practice, the nurse shows understanding and support.
A patient has been discharged home after a total mastectomy without reconstruction. The patient lives alone and has a home health referral. When the home care nurse performs the first scheduled visit this patient, what should the nurse assess? Select all that apply.
- A. Adherence to the exercise plan
- B. Overall psychological functioning
- C. Integrity of surgical drains
- D. Understanding of cancer E) Use of the breast prosthesis
Correct Answer: B
Rationale: B. Overall psychological functioning: It is crucial for the home care nurse to assess the patient's overall psychological functioning after a total mastectomy without reconstruction. The patient may be experiencing emotional distress, body image disturbances, anxiety, or depression related to the surgery and changes in physical appearance. The nurse should evaluate the patient's coping mechanisms, emotional well-being, and any signs of psychological implications to provide appropriate support and referral for mental health services if needed.
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?
- A. Slight morning discharge from the eye
- B. Any appearance of redness of the eye
- C. A scratchy feeling in the eye
- D. A new floater in vision
Correct Answer: B
Rationale: Redness of the eye after cataract surgery can be a sign of infection or inflammation, which are serious complications that require immediate medical attention. Redness may be accompanied by pain, swelling, or discharge, and if left untreated, it can lead to complications that may affect the surgical outcome and the patient's vision. Therefore, it is crucial for the patient to contact the office immediately if they notice any redness in their eye following cataract surgery.