Nokea
In the early postoperative period, what is the priority concern for Mr. L, who has a tracheostomy and partial laryngectomy?
- A. Possible infection related to chemotherapy and surgical procedure
- B. Poor nutritional intake related to dysphagia and malignancy
- C. Difficulty communicating needs because of the tracheostomy tube
- D. High risk for aspiration because of secretions and removal of epiglottis
Correct Answer: D
Rationale: The correct answer is D: High risk for aspiration because of secretions and removal of epiglottis. This is the priority concern for Mr. L due to the risk of food or liquid entering the airway, leading to aspiration pneumonia and respiratory distress. The tracheostomy and partial laryngectomy compromise the airway protection mechanism, increasing the risk of aspiration. Options A and B are not the priority as infection and poor nutrition can be managed after addressing the risk of aspiration. Option C, while important for communication, is not as immediately life-threatening as the risk of aspiration.
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Ms. C (bowel resection) repeatedly refuses to perform a return demonstration of any aspect of colostomy care. Despite steady improvement and independent resumption of other ADLs, she protests, "I'm too weak. You'll have to do it for me." At this point, what is the priority nursing concept to consider in planning interventions for Ms. C?
- A. Mobility
- B. Tissue integrity
- C. Functional ability
- D. Coping
Correct Answer: C
Rationale: The correct answer is C: Functional ability. This is because the priority nursing concept to consider in planning interventions for Ms. C is her ability to independently perform colostomy care. By refusing to demonstrate, she may be indicating a lack of functional ability to manage this aspect of self-care. This is essential for her long-term independence and quality of life. Mobility (choice A) is important but not the priority in this case. Tissue integrity (choice B) is also crucial but not as immediate as ensuring functional ability. Coping (choice D) is important for emotional well-being but does not address the primary issue of functional ability for self-care.
The hospital nurse educator develops an educational session for staff nurses on how to clearly record data in a patient's electronic medical record. Which key point should the nurse educator include in the teaching plan? (Select all that apply)
- A. A patient who is at high risk for falls will require more frequent documentation.
- B. The nurse should avoid labels (e.g., good, drug seeking, and lazy) to describe patients.
- C. Detailed and specific documentation is only required if a malpractice suit is expected.
- D. Each entry by the nurse in the electronic medical record should be clear and concise.
Correct Answer: A
Rationale: The correct answer is A because documenting the frequency of assessments and interventions for high-risk patients, such as those at risk for falls, is crucial for patient safety and care coordination. By documenting more frequently for high-risk patients, nurses can ensure timely interventions and prevent adverse events. This practice aligns with the principles of patient-centered care and risk management.
Choices B, C, and D are incorrect:
B: Avoiding labels in documentation is important for professionalism and ethical practice, but it is not directly related to the frequency of documentation for high-risk patients.
C: Detailed and specific documentation is required for all patients to ensure comprehensive care, not just for potential malpractice suits.
D: While clear and concise documentation is essential, this choice does not specifically address the need for more frequent documentation for high-risk patients.
Which statement, if made by the nurse, could positively affect the course of the patient's situation by suggestibility?
- A. "Breastfeeding will provide time to bond with your baby."
- B. "Breastfeeding will take longer than giving your baby a bottle."
- C. "You will need to be careful about taking medications while breastfeeding."
- D. "Breastfeeding mothers can develop infections that are serious."
Correct Answer: A
Rationale: The correct answer is A because it focuses on the positive aspect of breastfeeding, which is bonding with the baby. This statement can positively influence the patient's attitude and motivation towards breastfeeding. Choice B is incorrect as it introduces a negative aspect of breastfeeding. Choice C is unrelated to the positive impact of breastfeeding. Choice D introduces fear and negativity, which can hinder the patient's confidence in breastfeeding.
Which nonverbal action(s) would be consistent with an assertive style of communication? (Select all that apply)
- A. Relaxed posture
- B. Established eye contact
- C. Hands placed on hips
- D. Distant, soft voice
Correct Answer: A
Rationale: The correct answer is A (Relaxed posture) because assertive communication involves being confident and composed. A relaxed posture signifies confidence and comfort in oneself. Choices B (Established eye contact) can also be consistent with assertiveness as it shows engagement and confidence. Choices C (Hands placed on hips) may come across as aggressive rather than assertive. Choice D (Distant, soft voice) is more indicative of a passive communication style, lacking the firmness associated with assertiveness. In summary, choices B, C, and D are incorrect because they do not align with the confident and self-assured characteristics of assertive communication.
A hospital nurse is concerned about the demands of providing safe care to clients who are seriously ill. The nurse manager should suggest which intervention to effectively help the nurse balance the demanding work in the hospital setting?
- A. Delegate more tasks to the unlicensed nursing personnel on the unit.
- B. Request a transfer to another nursing care unit with patients who are stable.
- C. Write down stories in a journal about how caring makes a difference for patients.
- D. Use an assertive communication style for every patient3nurse interaction.
Correct Answer: B
Rationale: The correct answer is B: Request a transfer to another nursing care unit with patients who are stable.
Rationale:
1. By transferring to a unit with stable patients, the nurse can reduce the demands of caring for seriously ill clients.
2. This intervention helps in balancing the workload and provides a less stressful environment for the nurse.
3. It allows the nurse to focus on providing safe care without being overwhelmed by the demands of seriously ill patients.
Incorrect choices:
A: Delegating more tasks to unlicensed nursing personnel may not address the root cause of the nurse's concern and could potentially compromise patient safety.
C: Writing stories in a journal may be a helpful coping mechanism but does not directly address the nurse's workload concerns.
D: Using an assertive communication style is important but may not be the most effective solution for balancing the demands of caring for seriously ill clients.