Nokea
End-of-life palliative nursing care involves
- A. Constant assessment for changes in physiologic functioning.
- B. Administering large doses of analgesics to keep the patient sedated.
- C. Providing as little physical care as possible to prevent disturbing the patient.
- D. Encouraging the patient and family members to verbalize their feelings of sadness
Correct Answer: D
Rationale: Emotional and psychological support for both the patient and family is crucial in palliative care, helping them process feelings and find closure.
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For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the nursing assistant?
- A. Assist the patient to identify patterns of fatigue.
- B. Recommend participation in a walking program.
- C. Report the amount and type of food consumed from the tray.
- D. Check the skin for redness and irritation after the treatment.
Correct Answer: C
Rationale: Monitoring food intake is a straightforward task suitable for a nursing assistant, while identifying fatigue patterns or recommending exercise requires more clinical expertise.
What is an example of a pertinent negative finding during a physical examination?
- A. Chest pain that does not radiate to the arm
- B. Elevated blood pressure in a patient with hypertension
- C. Pupils that are equal and react to light and accommodation
- D. Clear and full lung sounds in a patient with chronic bronchitis
Correct Answer: A
Rationale: The correct answer is 'Chest pain that does not radiate to the arm.' Pertinent negatives highlight clinically significant absences of expected findings, helping rule out certain conditions like cardiac ischemia.
Which member of the surgical team does not scrub in the OR?
- A. The surgeon.
- B. The circulating nurse.
- C. The scrub nurse or surgical tech.
- D. The holding area nurse.
Correct Answer: B
Rationale: The circulating nurse remains outside the sterile field to assist with supplies.
A 44-year-old male client had abdominal surgery this morning. The nurse noticed a small amount of bloody drainage on the client's surgical dressing. This type of drainage is:
- A. serosanguineous.
- B. purulent.
- C. sanguineous.
- D. catarrhal.
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Purulent drainage usually indicates infection. This drainage should not be seen initially from a surgical incision. An incision with a Penrose drain may be expected to have a moderate amount of serosanguineous drainage in the first 24 hours, but in general drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
What are the recommendations that can help develop culturally sensitive nursing care?
- A. Learn about different cultures,avoid stereotypes and involve clients in decision-making.
- B. Focus solely on universal care standards.
- C. Ignore cultural differences.
- D. All of the above.
Correct Answer: A
Rationale: Understanding cultural nuances and involving clients in care decisions enhances cultural competence and improves outcomes.