Nokea
Mr. U (pulmonary resection) has developed a tension pneumothorax. He is currently receiving high-flow oxygen via nonrebreather mask but continues to experience respiratory distress. What is the priority action?
- A. Remove the occlusive dressing around the chest wound.
- B. Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
- C. Initiate cardiopulmonary resuscitation (CPR).
- D. Call for the crash cart and intubation equipment.
Correct Answer: B
Rationale: The correct answer is B: Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
Rationale:
1. Tension pneumothorax is a life-threatening emergency where air accumulates in the pleural space, causing lung collapse and increased pressure in the chest.
2. The standard treatment for tension pneumothorax is needle thoracostomy, which involves inserting a large-bore needle into the chest to release the trapped air.
3. In this scenario, Mr. U is in respiratory distress despite receiving high-flow oxygen, indicating a significant problem with ventilation that requires immediate intervention.
4. Performing a needle thoracotomy will rapidly decompress the tension pneumothorax, relieving pressure on the heart and lungs, and improving respiratory function.
5. This action takes precedence over other options such as removing the occlusive dressing, initiating CPR, or calling for intubation equipment, as immediate decompression is crucial in managing tension pneumoth
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While interviewing a Native American man for the admission history, the nurse should expect to:
- A. wait patiently through long pauses in the conversation.
- B. maintain eye contact with the patient.
- C. give the patient permission to speak.
- D. have another family member speak for the patient. Native Americans use long pauses in their conversation to better consider their answer and consider the question. The culturally sensitive nurse would wait quietly through the pauses.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the cultural communication norms of Native American individuals, who may take longer pauses during conversations to reflect and respond thoughtfully. By waiting patiently through these pauses, the nurse shows respect for the individual's communication style and allows for effective dialogue.
Option B is incorrect because maintaining constant eye contact may be perceived as confrontational or disrespectful in some Native American cultures. Option C is incorrect as it assumes the patient needs permission to speak, which may not align with their cultural norms. Option D is incorrect as it undermines the individual's autonomy and may not accurately represent their perspective.
The nursing student tearfully reports to the leader, "I took some flowers into Mr. N's (non- Hodgkin lymphoma) room to cheer him up, and he told me that he didn't think he was supposed to have flowers. I took them out of the room right away, and then I realized I had made a mistake." What should the team leader do first?
- A. Direct the student to read the isolation precautions before entering the room.
- B. Call the nursing instructor and report the student for making an error.
- C. Acknowledge and praise the student for taking responsibility for the mistake.
- D. Write an incident report and have the student and instructor sign it.
Correct Answer: C
Rationale: The correct answer is C because it is important to acknowledge and praise the student for taking responsibility for the mistake. By doing this, the team leader can encourage a culture of accountability and learning from errors. This approach supports the student's professional growth and self-awareness.
Option A is incorrect because the immediate focus should be on addressing the emotional response of the student and providing support rather than assigning blame. Option B is inappropriate as it could undermine the student's confidence and discourage future initiative. Option D is premature as it prioritizes paperwork over supporting the student's learning and emotional well-being.
The nurse can best ensure that communication is understood by:
- A. speaking slowly and clearly in the patient's native language.
- B. asking the family members whether the patient understands.
- C. obtaining feedback from the patient that indicates accurate comprehension.
- D. checking for signs of hearing loss or aphasia before communicating. The best way to determine understanding is to ask the patient. Factors such as anxiety, hearing acuity, language, aphasia, or lack of familiarity with medical jargon or routines can all contribute to misunderstanding.
Correct Answer: C
Rationale: The correct answer is C: obtaining feedback from the patient that indicates accurate comprehension. This is the best way to ensure effective communication because it directly involves the patient in the communication process, allowing for clarification if needed. By receiving feedback from the patient, the nurse can confirm whether the information has been understood correctly. This approach promotes active listening and engagement from the patient, enhancing the likelihood of accurate communication.
Incorrect choices:
A: Speaking slowly and clearly in the patient's native language may help, but it does not guarantee comprehension.
B: Asking family members may not accurately reflect the patient's understanding and could lead to miscommunication.
D: Checking for signs of hearing loss or aphasia is important, but it does not directly assess the patient's understanding of the communication.
The author describes the patient journey as driving down a country road and somehow getting lost. At that moment and time, all that is needed is clear directions about how to get to your destination, not about types of entertainment in the area. The same is true for patients. Accordingly, a part of each nursing assessment should include:
- A. Patient's need for information and level of understanding
- B. Detailed overview of disease process
- C. Specific examples from other patients with same disease
- D. Nurse's feelings about newest treatment modality
Correct Answer: A
Rationale: Step 1: Understanding the patient's need for information and level of understanding is crucial to providing appropriate care.
Step 2: Clear directions are necessary to guide patients, just like clear information is needed to guide their healthcare decisions.
Step 3: Assessing the patient's need for information helps tailor education to their level of understanding.
Step 4: This choice directly aligns with the analogy of providing clear directions for patients on their healthcare journey.
Summary: Choice A is correct as it emphasizes the importance of assessing the patient's need for information and understanding, which is essential for guiding them effectively. Choices B, C, and D are incorrect as they do not directly address the patient's need for information and understanding in the analogy provided.
Ms. G (breast lumpectomy) continues to be anxious and tearful, and she says that she has changed her mind about the surgery, saying, "I'm going to go home. I just can't deal with everything that is going on right now. I need some time to think about things." What is the best response?
- A. "It's okay to change your mind. You have the right to make your own decisions."
- B. "Please reconsider. This surgery is very important, and your health is the priority."
- C. "Would you like me to call your HCP, so you can discuss your concerns?"
- D. "I see you are very concerned. What things are you dealing with and thinking about?"
Correct Answer: A
Rationale: The correct answer is A because it acknowledges Ms. G's autonomy and respects her right to make decisions about her own body. By validating her feelings and choices, it helps build trust and rapport. Choice B is incorrect as it disregards Ms. G's emotional state and can come off as dismissive. Choice C assumes Ms. G needs immediate medical intervention without exploring her concerns further. Choice D, although showing empathy, does not directly address Ms. G's decision to change her mind about the surgery.