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During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
- A. Ask the social worker to investigate alternative housing arrangements.
- B. Ask the social worker to investigate community support agencies.
- C. Encourage the patient to explore surgical corrections for the vision problem.
- D. Arrange for referral to a rehabilitation facility for vision training.
Correct Answer: D
Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently.
A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management.
B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management.
C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.
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A nurse is reviewing results from a urine specimen.What will the nurse expect to see in a patient with a urinary tract infection?
- A. Casts
- B. Protein
- C. Crystals
- D. Bacteria
Correct Answer: D
Rationale: The correct answer is D: Bacteria. In a patient with a urinary tract infection (UTI), bacteria are typically present in the urine due to the infection of the urinary system. Bacteria may be detected through urine culture or microscopic examination.
A: Casts are not typically associated with UTIs but can indicate kidney disease.
B: Protein in the urine can indicate kidney damage or other issues, not specific to UTIs.
C: Crystals in the urine can be normal or indicate specific conditions, but they are not specific to UTIs.
In summary, the presence of bacteria in the urine is a key indicator of a UTI, while the other choices are more indicative of different conditions or factors.
A nurse is sitting at the patient’s bedside takinga nursing history. Which zone of personal space is the nurse using?
- A. Socio-consultative
- B. Personal
- C. Intimate
- D. Public
Correct Answer: B
Rationale: The nurse sitting at the patient's bedside is using the personal zone of personal space, which ranges from 18 inches to 4 feet. This distance allows for a close interaction suitable for taking a nursing history while maintaining a professional yet personal connection. The socio-consultative zone (A) is 4-12 feet, more appropriate for professional interactions. The intimate zone (C) is 0-18 inches, too close for an initial nursing history. The public zone (D) is 12 feet or more, too distant for a personal conversation.
A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style. A home health nurse is preparing for an initialhome visit. Which information should be included in the patient’s home care medical record?
- A. Nursing process form
- B. Step-by-step skills manual
- C. A list of possible procedures
- D. Reports to third-party payers
Correct Answer: D
Rationale: The correct answer is D: Reports to third-party payers. In home health care, it is essential to document and report patient care to third-party payers for reimbursement purposes. This includes detailed reports on the services provided, patient progress, and any changes in the care plan. This information is crucial for ensuring that the patient receives appropriate reimbursement for the care received.
Incorrect choices:
A: Nursing process form - While a nursing process form is important for documenting patient care, it is not specifically related to reporting to third-party payers.
B: Step-by-step skills manual - While a skills manual may be helpful for guiding care provision, it is not typically included in the patient's medical record.
C: A list of possible procedures - While a list of procedures may be useful for reference, it is not a formal part of the patient's medical record for home care documentation.
The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa?
- A. Female fetus, Mexican-American, primigravida
- B. Male fetus, Asian-American, previous preterm birth
- C. Male fetus, African-American, previous cesarean birth
- D. Female fetus, European-American, previous spontaneous abortion
Correct Answer: C
Rationale: The correct answer is C because African-American ethnicity and previous cesarean birth are established risk factors for placenta previa due to the potential for scarring and abnormal placental implantation. Male fetus does not influence the risk. Asian-American ethnicity and previous preterm birth are not significant risk factors. European-American ethnicity and previous spontaneous abortion are also not associated with an increased risk of placenta previa.
Which piece of data will the nurse use for “B” when using SBAR?
- A. Having chest pain
- B. Pulse rate of 108
- C. History of angina
- D. Oxygen is needed
Correct Answer: C
Rationale: The nurse will use the history of angina for "B" when using SBAR because it provides relevant background information about the patient's cardiac condition. This helps the nurse understand the context of the current situation and make appropriate decisions. Pulse rate of 108 (choice B) is a specific vital sign and not an appropriate choice for "B" in SBAR. Having chest pain (choice A) is important but does not provide the necessary background information like the history of angina does. Oxygen being needed (choice D) is a current intervention and not relevant for "B" in SBAR, which focuses on providing background information.