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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 primary care provider informs the student nurse that he would like to give a telephone order. The best response by the student is:
- A. document the telephone order on the primary care provider's orders.
- B. ask another student to listen as a witness to the telephone order.
- C. tape record the primary care provider giving the order to the student nurse.
- D. ask the registered nurse to take the telephone order.
Correct Answer: D
Rationale: The correct answer is D because asking the registered nurse to take the telephone order ensures accuracy and accountability. The registered nurse is trained to accurately transcribe orders and can verify the details with the primary care provider if needed. This also follows the chain of command and delegation principles in healthcare.
Choice A is incorrect because the student nurse should not document the order directly without proper verification. Choice B is incorrect as having another student as a witness does not guarantee accuracy or proper documentation. Choice C is incorrect as recording the order could violate patient privacy laws and does not involve a healthcare professional in the transcription process.
The nurse prepares to obtain a health history from a hospitalized patient. Which action by the nurse is appropriate?
- A. Set time limits for the interview to reduce cost.
- B. Avoid asking questions that may upset the patient.
- C. Respect the patient's privacy by closing the door.
- D. Stand at the foot of the bed to maintain eye contact.
Correct Answer: C
Rationale: The correct answer is C: Respect the patient's privacy by closing the door. Closing the door ensures confidentiality and privacy during the health history interview, promoting trust between the nurse and patient. This setting allows for open communication and prevents distractions. Options A and D are incorrect because setting time limits for the interview to reduce cost and standing at the foot of the bed to maintain eye contact do not prioritize patient privacy and comfort. Option B is incorrect because avoiding questions that may upset the patient may hinder the nurse's ability to gather important information for proper care.
As an experienced staff nurse, you have been asked to create a teaching guide for nursing orientation on respect. Accessing the list from Ehow about being genuine, you would include all of the following. (Select all that apply)
- A. Acting natural around others
- B. Listening when others are speaking
- C. Denying your mistakes
- D. Compliment only when you sincerely mean it
Correct Answer: A
Rationale: Step 1: Being genuine means acting natural around others, which fosters trust and respect in relationships.
Step 2: Acting natural promotes authenticity and conveys sincerity, enhancing communication and connection.
Step 3: Listening when others are speaking is also crucial for respect, as it shows empathy and understanding.
Step 4: Denying mistakes goes against respect and honesty, leading to mistrust and lack of credibility.
Step 5: Complimenting only when sincere is important, but not directly related to being genuine in this context.
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.
The nursing staff are making suggestions about how to help Ms. C (bowel resection) overcome her reluctance to perform colostomy care. Which suggestion will the team leader try first?
- A. Verbally reexplain the procedure and give her written material.
- B. Have a family member come in and do it for her.
- C. Continue to do it for her until she is ready.
- D. Ask her to hold the clamp while the bag is being emptied.
Correct Answer: A
Rationale: The correct answer is A because it involves providing Ms. C with information and resources to help her understand and feel more comfortable with the colostomy care procedure. Verbally reexplaining the procedure and providing written material will empower her with knowledge and autonomy. Choice B undermines her independence and may not address her reluctance. Choice C promotes dependency rather than encouraging her to take ownership of her care. Choice D involves a hands-on approach that may not address her underlying concerns or fears about the procedure. Overall, choice A is the most appropriate initial step to support Ms. C in overcoming her reluctance.