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During a patient consultation, the nurse notices the patient seems anxious and is avoiding eye contact. What is the most appropriate action for the nurse to take?
- A. Continue with the consultation without addressing the patient's behavior.
- B. Ask the patient if they are feeling anxious and if they would like to talk about it.
- C. Ignore the patient's behavior and focus solely on the medical information.
- D. Tell the patient to relax and stop being anxious.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when noticing that the patient seems anxious and is avoiding eye contact is to ask the patient if they are feeling anxious and if they would like to talk about it. This approach shows empathy, concern, and openness to addressing the patient's emotional state. By directly acknowledging the patient's behavior and giving them the opportunity to express their feelings, the nurse can create a supportive and caring environment that promotes effective communication and trust between the patient and healthcare provider. It is important to consider the patient's emotional well-being alongside their physical health during consultations.
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It a medicine is unavailable and therefore not given to the patient, how is it charted?
- A. Leave it blank.
- B. Sign and make an explanation in the Nurses Notes.
- C. With an asterisk or mark, as per hospital protocol.
- D. Write the letter.
Correct Answer: B
Rationale: When a medication is unavailable and therefore not given to the patient, it is important to document this in the Nurses Notes along with an explanation. Leaving it blank (Option A) may lead to confusion or errors as the reason for not administering the medication would not be clear. Using an asterisk or mark as per hospital protocol (Option C) may not provide enough information about why the medication was missed. Writing the letter (Option D) without any explanation would not suffice in terms of documentation and accountability. Therefore, signing and making an explanation in the Nurses Notes (Option B) is the correct way to chart when a medication is unavailable. This ensures proper documentation of the situation and helps in maintaining the continuity of care for the patient.
Nurse Nora notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing the frequency of her contractions after she receives oxytocin. what would be the nurse's FIRST action?
- A. Give an emergency bolus of oxytocin to relaxed the uterus
- B. Discontinue the administration of the oxytocin infusion
- C. Increase the rate of client's IV infusion
- D. Ask client to turn to her left side and breathe deeply
Correct Answer: B
Rationale: Patient's uterine contractions lasting 70 seconds and occurring every 90 seconds signify hyperstimulation, which can be a serious complication associated with oxytocin administration. This may result in decreased uterine perfusion, fetal distress, and other adverse effects. The first action should be to discontinue the oxytocin infusion to prevent further complications and allow the uterus to relax. Observations and assessment should continue to monitor the patient's condition and response after discontinuing the infusion. Giving an emergency bolus of oxytocin or increasing the IV infusion rate would exacerbate the hyperstimulation, and turning the client to her left side and breathing deeply would not address the underlying issue of oxytocin-induced hyperstimulation.
During CPR, which of the following actions should be performed immediately after activating the emergency response system?
- A. Start chest compressions.
- B. Check for breathing.
- C. Perform abdominal thrusts.
- D. Assess pulse.
Correct Answer: A
Rationale: After activating the emergency response system, the immediate priority in CPR is to begin chest compressions to support blood circulation. High-quality chest compressions are crucial in providing oxygen to vital organs, especially the brain, during cardiac arrest. Starting chest compressions promptly can improve the chances of survival for the person in need of CPR. Checking for breathing, performing abdominal thrusts, or assessing pulse should only be done after initiating chest compressions in the CPR sequence.
The nurse must include in the education plan, which of the following components? (Select all that apply.) I. Objectives II. Content and time allotment III. Teaching and learning resources IV. Evaluation parameters
- A. II, III, and IV
- B. I, II, III and IV
- C. I, III, and IV
- D. I, II, and III
Correct Answer: B
Rationale: In order to create a comprehensive education plan, the nurse must include all of the listed components.
A patient is prescribed an anticoagulant for the prevention of venous thromboembolism (VTE). Which laboratory parameter should the nurse monitor closely during anticoagulant therapy?
- A. Platelet count
- B. International normalized ratio (INR)
- C. Serum sodium levels
- D. Blood urea nitrogen (BUN)
Correct Answer: B
Rationale: The nurse should monitor the International Normalized Ratio (INR) closely during anticoagulant therapy for the prevention of VTE. The INR measures the clotting ability of the blood and is used to monitor the effectiveness of anticoagulant therapy, such as warfarin. Maintaining the INR within the target therapeutic range is crucial to prevent both excessive bleeding due to over-anticoagulation and clotting events due to under-anticoagulation. Close monitoring of the INR helps healthcare providers adjust the anticoagulant dosage as needed to ensure optimal therapeutic outcomes and minimize risks. Platelet count, serum sodium levels, and blood urea nitrogen (BUN) are important laboratory parameters to monitor for other medical conditions but are not specific to anticoagulant therapy.