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After the BCG treatment, the team leader delegates disposal of the fluid contents in Mr. B's (bladder cancer) urinary drainage bag to the UAP. What instructions should be given to the UAP?
- A. "No special handling of the bag or its contents is required."
- B. "Wear a lead apron when you are emptying the drainage container."
- C. "Discard the fluid in the toilet and disinfect the toilet with bleach for 6 hours."
- D. "Wear sterile gloves when you are handling the bag and its contents."
Correct Answer: C
Rationale: The correct answer is C because after BCG treatment, the fluid in the urinary drainage bag is considered hazardous due to the live bacteria used in the treatment. Therefore, instructing the UAP to discard the fluid in the toilet and disinfect it with bleach is crucial to prevent the spread of infection. This step helps to ensure proper disposal and minimize the risk of exposure to others.
Choice A is incorrect because special handling is indeed required due to the nature of the contents. Choice B is incorrect as wearing a lead apron is not necessary for handling the fluid in the urinary drainage bag. Choice D is also incorrect as sterile gloves are not specifically required for this task; instead, proper disinfection of the toilet is essential.
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The nurse needs to obtain a health history from a Spanish-speaking patient. Which action by the nurse is best?
- A. Ask a bilingual friend of the patient to interpret.
- B. Use nonverbal communication and draw pictures.
- C. Request a Spanish-speaking medical interpreter.
- D. Interview the patient's English-speaking daughter.
Correct Answer: C
Rationale: The correct answer is C because using a professional medical interpreter ensures accurate communication, maintains patient confidentiality, and upholds ethical standards. Step 1: Requesting a Spanish-speaking medical interpreter ensures clear understanding of the patient's health history. Step 2: Using a professional interpreter avoids potential misinterpretations that may arise from using untrained individuals. Step 3: Interviewing the patient's English-speaking daughter may lead to inaccuracies and breaches patient confidentiality. Step 4: Asking a bilingual friend of the patient to interpret lacks professionalism and may result in miscommunication.
A patient is attracted to the nurse and attempts to initiate a social relationship. It is most appropriate for the nurse to take which action?
- A. Encourage the client's behavior to develop a trusting nurse3client relationship.
- B. Inform the charge nurse of the situation and ask for a different patient assignment.
- C. Tell the patient that the relationship must remain professional at all times.
- D. Determine if the patient can be transferred to another nursing care unit.
Correct Answer: C
Rationale: The correct answer is C because it maintains professional boundaries, prioritizing the patient's well-being. By clearly stating that the relationship must remain professional, the nurse sets clear boundaries and avoids any potential ethical issues. Choice A is incorrect as it can lead to boundary violations and compromise patient care. Choice B is incorrect as it does not address the situation directly and may not be necessary if proper boundaries are set. Choice D is incorrect as transferring the patient may not address the underlying issue and is not a standard response to this situation.
The nurse cares for a patient with urinary incontinence after a stroke. Which response by the nurse is best?
- A. "You seem upset about this. We can work together on a bladder retraining program."
- B. "I don't mind cleaning up your mess. I am used to it because my child does this at night."
- C. "Don't be embarrassed. A lot of patients have this problem after a stroke."
- D. "I will bring you some diapers to wear instead of having you wet the bed all the time."
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy, collaboration, and a patient-centered approach. By acknowledging the patient's feelings and offering to work together on a solution, the nurse shows respect and support. This response promotes patient dignity and autonomy.
Choice B is incorrect as it is unprofessional and may be perceived as insensitive. Choice C, while acknowledging the commonality of the issue, lacks a proactive approach to address the problem. Choice D does not promote independence or address the patient's emotional needs.
There are 2 hours left before the shift ends. The new UAP tells the team leader that she must leave now because she has a family emergency. What should the team leader do? Select all that apply.
- A. Ask her what tasks and duties are pending for the next 2 hours.
- B. Call a UAP who is scheduled for the next shift to come early.
- C. Allow her to leave but remind her she is still on probation as a new staff member.
- D. Call another unit and see if there is a UAP who could float to the unit.
Correct Answer: A
Rationale: The correct answer is A. The team leader should ask the UAP what tasks and duties are pending for the next 2 hours to assess the workload and determine if it's possible for the UAP to leave immediately. By understanding the pending tasks, the team leader can make an informed decision on whether the UAP leaving will impact patient care or workload. This approach ensures that patient care is not compromised and that the team's responsibilities are managed effectively.
Choices B, C, and D are incorrect because they do not directly address the immediate situation of the UAP needing to leave due to a family emergency. Calling another UAP, reminding the UAP of probation status, or seeking assistance from another unit may not be necessary or relevant if the tasks can be managed effectively without the UAP who needs to leave. These options do not prioritize understanding the pending tasks and duties to make an informed decision.
The nurse cares for an adult client who is diagnosed with active tuberculosis. Which action, if performed by the nurse during introductions, shows respect for the client? (Select all that apply)
- A. Maintain eye contact by looking at the client.
- B. Avoid touch to reduce transmission of the disease.
- C. Stay at least 4 to 6 feet away from the client.
- D. Briefly converse about the weather to break the ice.
Correct Answer: A
Rationale: The correct answer is A. Maintaining eye contact by looking at the client during introductions shows respect by acknowledging the client as an individual and demonstrating active listening. This helps establish trust and rapport.
Incorrect choices:
B: Avoiding touch may be necessary for infection control, but it does not necessarily show respect for the client.
C: Staying 4 to 6 feet away may be necessary for infection control, but it does not demonstrate respect or engagement with the client.
D: Briefly conversing about the weather is a social nicety but may not convey the same level of respect and attentiveness as making eye contact.