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In the operating room, personnel should be responsible for ensuring cleanliness, proper temperature, humidity, and lighting. Who carries those responsibilities?
- A. circulating nurse
- B. scrub nurse
- C. surgeon
- D. anesthesiologist
Correct Answer: A
Rationale: The correct answer is A: circulating nurse. The circulating nurse is responsible for maintaining cleanliness, ensuring proper temperature, humidity, and lighting in the operating room. They coordinate activities, manage supplies, and ensure a safe environment for the surgical team. The scrub nurse assists the surgeon with instruments and supplies, not environmental conditions. The surgeon's main focus is on performing the surgery, not environmental management. The anesthesiologist is responsible for administering anesthesia and monitoring the patient's vital signs, not the operating room environment.
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After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
- A. To form a language that can be encoded only by nurses
- B. To distinguish the nurse’s role from the physician’s role
- C. To develop clinical judgment based on other’s intuition
- D. To help nurses focus on the scope of medical practice
Correct Answer: D
Rationale: The correct answer is D because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery.
A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs.
B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role.
C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.
A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:
- A. fluid volume excess
- B. incontinence, bowel
- C. fluid volume deficit
- D. diarrhea
Correct Answer: C
Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.
A patient asks the nurse what her diagnosis of heart failure means. Which of the ff. is the nurse’s best response?
- A. “Your heart briefly stops.”
- B. “Your heart has an area of muscle that is dead.”
- C. “Your heart is pumping to much blood.”
- D. “Your heart is not an efficient pump.”
Correct Answer: D
Rationale: The correct answer is D: “Your heart is not an efficient pump.” This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention.
Explanation:
1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly.
2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart.
3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.
A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. The ff. nursing interventions might be recommended to help prevent aspiration during eating except:
- A. Provide clear liquids only until the patient can swallow solid foods.
- B. Have the patient swallow twice after each bite
- C. Place food on the unaffected side of the patient’s mouth
- D. Check if the patient’s mouth for pocketing of food
Correct Answer: A
Rationale: The correct answer is A because providing clear liquids only until the patient can swallow solid foods is not a recommended nursing intervention to prevent aspiration. Clear liquids do not require the same level of swallowing coordination as solid foods, so it may not help improve swallowing ability.
B: Having the patient swallow twice after each bite can help clear the throat and reduce the risk of aspiration.
C: Placing food on the unaffected side of the mouth can help direct the food towards the stronger side for swallowing.
D: Checking the patient's mouth for pocketing of food is important to ensure that food is not being retained in the mouth, which could lead to aspiration.
A client asks the nurse what PSA is. The nurse should reply that is stands for:
- A. Prostate-specific antigen, which is used to screen for prostate cancer
- B. Protein serum antigen, which is used to determine protein levels
- C. Pneumococcal strep antigen, which is bacteria that causes pneumonia
- D. Papanicolua-specific antigen, which is used to screen for cervical cancer
Correct Answer: A
Rationale: The correct answer is A: Prostate-specific antigen, which is used to screen for prostate cancer. PSA is a protein produced by the prostate gland, and elevated levels may indicate prostate cancer. Choice B is incorrect as PSA is specific to the prostate, not protein levels. Choice C is incorrect as pneumococcal strep antigen is related to pneumonia, not PSA. Choice D is incorrect as Papanicolua-specific antigen is not a recognized term, and PSA is not used to screen for cervical cancer.