Nokea
Before giving the patient an intermittent gastric tube feeding, what should the nurse do?
- A. Make sure that the tube is secured to the gown with a safety pin.
- B. Inject air into the stomach via the tube and auscultate.
- C. Have the tube feeding at room temperature.
- D. Check to make sure pH is at least 5
Correct Answer: B
Rationale: The correct answer is B because injecting air into the stomach via the tube and auscultating helps confirm the tube placement in the stomach before administering the feeding. This step ensures the safety of the patient by preventing accidental lung feeding.
Choice A is incorrect because securing the tube with a safety pin to the gown is not a standard practice and can lead to complications.
Choice C is incorrect because the temperature of the feeding does not affect the tube placement or safety.
Choice D is incorrect because checking the pH level is not a reliable method for verifying tube placement.
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A patient is receiving opioids for pain. Which bowel assessment is a priority?
- A. Clostridium difficile
- B. Constipation
- C. Hemorrhoids
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is B: Constipation. When a patient is receiving opioids, constipation is a common side effect due to decreased gut motility. It is a priority assessment because untreated constipation can lead to serious complications such as bowel obstruction. Monitoring for constipation allows for early intervention with stool softeners or laxatives to prevent complications.
Incorrect choices:
A: Clostridium difficile - While important to consider in patients on antibiotics, it is not directly related to opioid use.
C: Hemorrhoids - Although opioids can contribute to constipation which may exacerbate hemorrhoids, it is not the priority assessment.
D: Diarrhea - Opioids typically cause constipation, so diarrhea is less likely to be a priority concern in this scenario.
A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond?
- A. Not until the drain is removed
- B. On the second postoperative day
- C. Now, if you wash gently with soap and water
- D. Seven days after your surgery
Correct Answer: A
Rationale: The correct answer is A: Not until the drain is removed. After a mastectomy with immediate reconstruction, there is typically a drain in place to collect fluid. Showering before the drain is removed can increase the risk of infection and disrupt the healing process. It is important to wait until the healthcare provider removes the drain to ensure proper healing and reduce the risk of complications.
Summary:
B: On the second postoperative day - Too early, the drain needs to be removed first.
C: Now, if you wash gently with soap and water - Incorrect, the drain should be removed before showering.
D: Seven days after your surgery - Incorrect, waiting for a specific number of days is not necessary, it depends on when the drain is removed.
The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action?
- A. Ask the patient when she last had anything to eat or drink.
- B. Take a culture of the lesions to verify the involved organism.
- C. Ask the patient if she has had unprotected sex since her outbreak.
- D. Use electronic fetal surveillance to determine a baseline fetal heart rate.
Correct Answer: D
Rationale: The correct answer is D: Use electronic fetal surveillance to determine a baseline fetal heart rate. This is important in assessing the well-being of the fetus during labor, especially in the presence of genital herpes lesions. Monitoring the fetal heart rate helps in detecting any signs of distress or compromise due to maternal infection.
A: Asking about the patient's last intake is important but not the immediate priority when managing a patient with active genital herpes lesions in labor.
B: Taking a culture of the lesions might be helpful but not the immediate action needed in this situation.
C: Asking about unprotected sex is relevant but not as critical as monitoring the fetal well-being during labor in this scenario.
Overall, the most critical action is to monitor the fetal heart rate for any signs of distress related to the maternal herpes infection.
A nurse is a member of an interdisciplinary teamthat uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
- A. Add this data to the problem list.
- B. Focus chart using the DAR format.
- C. Document the variance in the patient’s record.
- D. Report a positive variance in the next interdisciplinary team meeting.
Correct Answer: C
Rationale: The correct answer is C: Document the variance in the patient’s record. By documenting the variance in the patient's record, the nurse can provide a clear record of the deviation from the critical pathway. This documentation is essential for tracking the patient's progress accurately and identifying potential issues that may require intervention. It allows for proper communication among the interdisciplinary team and ensures that everyone is aware of the deviation.
Choice A is incorrect because adding data to the problem list may not provide a comprehensive record of the variance. Choice B is incorrect because focusing on charting using the DAR format does not address the deviation from the critical pathway. Choice D is incorrect because reporting a positive variance in the next team meeting may not accurately reflect the patient's actual progress and may lead to miscommunication within the team.
A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?
- A. The patient should not be in contact with the baby after delivery.
- B. The patients treatment poses no risk to his daughter or her infant.
- C. The patients brachytherapy may be contraindicated for safety reasons.
- D. The patient should avoid close contact with his daughter for 2 months.
Correct Answer: B
Rationale: The correct answer is B because brachytherapy does not pose a risk to the patient's daughter or her unborn child. Brachytherapy involves placing radioactive sources inside or near the tumor, which does not make the patient radioactive. The radiation does not travel far and does not pose a risk to others. Therefore, the daughter and her infant are safe from any radiation exposure. Choices A, C, and D are incorrect because there is no need for the patient to avoid contact with the baby after delivery, the brachytherapy is not contraindicated for safety reasons, and there is no requirement for the patient to avoid close contact with his daughter for 2 months.