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During a shift handover, the nurse receives information about a patient's condition from the outgoing nurse. What action by the nurse demonstrates effective communication during the handover process?
- A. Interrupting the outgoing nurse to ask questions
- B. Writing down the information without asking for clarification
- C. Summarizing key points and asking clarifying questions as needed
- D. Disregarding the information and relying on personal assessment later
Correct Answer: C
Rationale: Option C, summarizing key points and asking clarifying questions as needed, demonstrates effective communication during the handover process. This action ensures that the nurse fully understands the information being provided and helps to prevent misunderstandings or missing critical details. By summarizing key points, the nurse confirms their understanding and can ask for clarification on any areas that are unclear. Effective communication during handovers is essential for maintaining patient safety and continuity of care.
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Which diagnostic test could be useful in confirming the diagnosis of Dengue Fever?
- A. Rumpell -Leede
- B. Elisa
- C. Mantoux
- D. Widal
Correct Answer: B
Rationale: The diagnostic test that could be useful in confirming the diagnosis of Dengue Fever is the ELISA test. ELISA stands for Enzyme-Linked Immunosorbent Assay. This test detects the presence of dengue virus-specific antibodies (IgM and IgG) in the blood of an individual suspected to have dengue fever. Elevated levels of these antibodies indicate a recent or ongoing dengue virus infection. ELISA is a standard and reliable test used in diagnosing dengue fever, along with clinical symptoms and other laboratory tests.
A patient is prescribed a proton pump inhibitor (PPI) for the treatment of peptic ulcer disease. Which adverse effect should the nurse monitor closely in the patient?
- A. Constipation
- B. Hypokalemia
- C. Diarrhea
- D. Clostridium difficile infection
Correct Answer: B
Rationale: Proton pump inhibitors (PPIs) are commonly prescribed for conditions involving excessive stomach acid production, such as peptic ulcer disease. One of the potential adverse effects of PPIs, such as omeprazole or pantoprazole, is the risk of hypokalemia. Hypokalemia is a condition characterized by low levels of potassium in the bloodstream. Prolonged use of PPIs can inhibit the absorption of potassium in the intestines, leading to a decrease in potassium levels in the body. Hypokalemia can present with symptoms such as muscle weakness, fatigue, irregular heartbeat, and in severe cases, it can result in life-threatening complications like cardiac arrhythmias. Therefore, it is essential for the nurse to closely monitor the patient for signs and symptoms of hypokalemia while on PPI therapy, especially if the patient is at risk for developing electrolyte imbalances.
A patient is prescribed an opioid analgesic for the management of acute pain. Which adverse effect should the nurse monitor closely in the patient?
- A. Hypertension
- B. Hypoglycemia
- C. Respiratory depression
- D. Hyperkalemia
Correct Answer: C
Rationale: Opioid analgesics are known to suppress the respiratory centers in the brain, leading to respiratory depression as a side effect. This adverse effect is particularly dangerous and potentially life-threatening, especially in patients who are opioid-naive or when high doses are administered. Therefore, it is crucial for the nurse to closely monitor the patient's respiratory rate, depth, and effort while on opioid analgesic therapy to detect early signs of respiratory depression and intervene promptly to prevent complications. Hypertension, hypoglycemia, and hyperkalemia are not commonly associated with opioid analgesics.
Ms. C is at risk for refeeding syndrome that is caused by rapid feeding. What should be the priority action of the health care team to prevent complications associated with this syndrome?
- A. Assess for signs of pallor of the extremities and sluggish capillary refill
- B. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention
- C. Observe for signs of secret purging and ingestion of water to increase weight
- D. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention
Correct Answer: B
Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.
The applicant was further asked about an incident report. Which of the following is a PRIORITY Case for an incident report be accomplished?
- A. Patient fell from the bed.
- B. Refusal to go to the physical therapy session.
- C. A visitor encourages a patient on bed rest to ambulate.
- D. Nurse left before his duty ends.
Correct Answer: A
Rationale: A patient falling from the bed is a critical incident that must be prioritized for an incident report. Patient falls can lead to injuries, complications, or even serious consequences. Documenting this incident is crucial for analyzing the cause of the fall, implementing prevention measures, and ensuring patient safety. Additionally, reporting patient falls is a standard practice in healthcare settings to maintain transparency and accountability in patient care.