Nokea
In providing tracheostomy care which of the following is the nurse's PRIORITY nursing action? The nurse ________.
- A. Cuts the dressing using sterile scissors
- B. Clean the incisions with iodine-based antiseptic
- C. Secures clean ties before removing soiled ones
- D. Uses clean technique
Correct Answer: C
Rationale: The correct answer is C: Secures clean ties before removing soiled ones. This is the priority action because securing clean ties prevents accidental dislodgement of the tracheostomy tube, ensuring the patient's airway remains patent. Cutting the dressing (A) or cleaning the incisions (B) can be important but not as critical as securing the tube. Using clean technique (D) is essential but not the priority in this situation.
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To achieve organized work flow in the unit the staff must be aware of the head nurse's role. What is the PRIMARY purpose of supervision and delegation?
- A. Enhances the delivery of quality nursing care
- B. Influences organization's approach in personnel evaluation
- C. Improves staff attendance in seminars
- D. Assigns any staff to do the tasks or project.
Correct Answer: A
Rationale: The correct answer is A: Enhances the delivery of quality nursing care. Supervision and delegation are essential in ensuring efficient and effective healthcare delivery. By supervising and delegating tasks appropriately, the head nurse can ensure that staff members are performing their duties competently, which ultimately leads to improved quality of patient care. Supervision helps in monitoring staff performance, providing feedback, and offering guidance when needed. Delegation ensures that tasks are allocated to the right staff members based on their skills and abilities, optimizing the workflow. Choices B, C, and D are incorrect because they do not directly relate to the primary purpose of supervision and delegation, which is to enhance the quality of nursing care through effective oversight and task allocation.
A patient expresses concerns about the financial implications of their treatment plan. What is the nurse's best response?
- A. Dismiss the patient's concerns and assure them that the treatment plan is necessary.
- B. Provide the patient with information about financial assistance programs and resources.
- C. Ignore the patient's concerns and proceed with implementing the treatment plan.
- D. Tell the patient that financial concerns should not affect their decision-making.
Correct Answer: B
Rationale: The correct answer is B because the nurse's role is to address the holistic needs of the patient, including financial concerns. Providing information about financial assistance programs and resources shows empathy and supports the patient in making informed decisions.
Choice A is incorrect because dismissing the patient's concerns can lead to a breakdown in trust and communication. Choice C is incorrect as ignoring the patient's concerns is not addressing the patient's needs. Choice D is incorrect because financial concerns are valid and should be considered in decision-making.
Which of the following interventions is the KEY to increasing the survival rates of clients with lung cancer?
- A. High-dose chemotherapy
- B. Smoking cessation
- C. Early bronchoscopy
- D. Early detection
Correct Answer: B
Rationale: The correct answer is B: Smoking cessation. Smoking is the leading cause of lung cancer, so quitting smoking is crucial in preventing and improving survival rates. Smoking cessation reduces the risk of developing lung cancer and improves treatment outcomes. High-dose chemotherapy (A) may be part of the treatment plan, but quitting smoking is more impactful. Early bronchoscopy (C) and early detection (D) are important, but without addressing the root cause (smoking), the survival rates will not significantly increase.
A patient presents with palpitations, dizziness, and syncope. An electrocardiogram (ECG) shows ventricular tachycardia. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Atrial fibrillation
- D. Ventricular tachycardia
Correct Answer: D
Rationale: The correct answer is D: Ventricular tachycardia. Ventricular tachycardia is a serious arrhythmia that can lead to palpitations, dizziness, and syncope due to the rapid and abnormal heart rhythm originating in the ventricles. This arrhythmia can be life-threatening if not promptly treated.
A: Stable angina is characterized by chest discomfort or pain due to reduced blood flow to the heart muscle, usually during physical exertion or stress. It does not typically present with palpitations, dizziness, or syncope.
B: Unstable angina is a more severe form of angina where symptoms occur even at rest. While it can lead to serious complications like heart attack, it does not commonly present with palpitations, dizziness, or syncope.
C: Atrial fibrillation is a common arrhythmia originating in the atria, leading to an irregular and often rapid heartbeat. While it can cause palpitations and dizziness,
Nurse Chona read in one nurse's notes chart this documentation: "Refused to eat and fell from bed". Which of the following is lacking in this documentation?
- A. Time of complaint, for missed and reaction on fall incurred.
- B. Referrals made on fall medications given and reasons of falling.
- C. Contents or complaints, reasons of refusing meal and nature of fall.
- D. Time of eating, medications for back pain and intense of pain.
Correct Answer: C
Rationale: The correct answer is C because the documentation lacks essential details regarding the contents of the complaints, reasons for refusing the meal, and the nature of the fall. This information is crucial for understanding the patient's condition and providing appropriate care. Choice A is not directly related to the documentation provided. Choice B is about referrals and medications, which are not mentioned in the documentation. Choice D is about eating time and medications for pain, which are also not relevant to the documentation provided. Therefore, the correct answer is C as it addresses the specific missing information in the nurse's notes.