Nokea
Nurses agree to be advocates for their patients. Practice of advocacy calls for the nurse to:
- A. Seek out the nursing supervisor in conflicting situations
- B. Work to understand the law as it applies to the client's clinical condition.
- C. Assess the client's point of view and prepare to articulate this point of view.
- D. Document all clinical changes in the medical record in a timely manner.
Correct Answer: C
Rationale: The practice of advocacy in nursing involves assessing the client's point of view and preparing to articulate this viewpoint. Advocacy requires that nurses actively listen to their patients, understand their perspectives, and ensure that their needs and wishes are communicated effectively within the healthcare team. By advocating for the client's point of view, nurses can help empower their patients to make informed decisions about their care and ensure that their best interests are always prioritized.
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During surgery, the nurse notices a discrepancy between the surgical count and the number of instruments on the sterile field. What should the nurse do?
- A. Re-count the instruments on the sterile field
- B. Document the discrepancy in the surgical count log
- C. Continue with the procedure as planned
- D. Inform the surgical team and initiate a thorough search
Correct Answer: D
Rationale: If a nurse notices a discrepancy between the surgical count and the number of instruments on the sterile field during surgery, it is crucial to inform the surgical team immediately and initiate a thorough search. Patient safety is of utmost importance, and any missing instruments could potentially pose a risk to the patient. By informing the team and conducting a thorough search, the missing instrument can be located promptly to ensure it is not inadvertently left inside the patient's body. Continuing with the procedure or ignoring the discrepancy without further investigation could lead to serious consequences for the patient's well-being. It is always better to address any discrepancies or concerns during surgery proactively to maintain a high standard of patient care and safety.
A patient undergoing mechanical ventilation in the ICU develops ventilator-associated pneumonia (VAP). What intervention should the healthcare team prioritize to manage the patient's respiratory infection?
- A. Administer broad-spectrum antibiotics targeting common pathogens.
- B. Perform endotracheal suctioning to clear airway secretions.
- C. Implement oral hygiene measures to reduce bacterial colonization.
- D. Recommend early mobilization to prevent complications of immobility.
Correct Answer: A
Rationale: Ventilator-associated pneumonia (VAP) is a serious complication in patients receiving mechanical ventilation in the ICU. The priority intervention to manage respiratory infection in a patient with VAP is the administration of appropriate antibiotics to target and eliminate the causative pathogens. Broad-spectrum antibiotics are usually initiated empirically to cover a wide range of potential pathogens commonly associated with VAP, such as Pseudomonas aeruginosa, Staphylococcus aureus, and Acinetobacter species. Timely initiation of antibiotic therapy is crucial in improving outcomes and reducing morbidity and mortality associated with VAP. Other interventions like endotracheal suctioning, oral hygiene measures, and early mobilization are also important in preventing complications and promoting recovery, but the primary focus should be on treating the infection with antibiotics.
Nurse Gina has also to consider in terms of financial status most of the elderly are
- A. Sufficient
- B. disoriented
- C. Dependent to others financially
- D. Have pension
Correct Answer: C
Rationale: Nurse Gina has to consider that most of the elderly are dependent on others financially. This is an important factor to take into account when planning and providing care for elderly patients. Many elderly individuals rely on financial assistance from family members, government programs, or retirement funds. Understanding the financial status of elderly patients helps nurses like Gina provide adequate care and support to meet their needs effectively. This can involve coordinating with social services or financial assistance programs to ensure that the patients' financial concerns are addressed along with their healthcare needs.
A woman in active labor presents with a prolonged latent phase, characterized by irregular and infrequent contractions. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Pelvic outlet obstruction
- C. Maternal exhaustion
- D. Fetal macrosomia
Correct Answer: A
Rationale: Maternal dehydration can contribute to a prolonged latent phase during labor. Dehydration can lead to reduced blood volume and electrolyte imbalances, which can result in ineffective uterine contractions. Without adequate hydration, the uterus may not contract effectively, causing irregular and infrequent contractions. It is important for the nurse to assess the woman's hydration status and encourage her to stay hydrated during labor to help regulate contractions and progress labor.
When writting a memorandum, which of the following is the MOST important guideline
- A. Purpose is included
- B. Friendly tone
- C. Content clear
- D. One topic at a time
Correct Answer: C
Rationale: When writing a memorandum, clarity in the content is the most important guideline to follow. It is crucial that the information provided in the memorandum is clearly understood by the recipients. Clear content ensures that the intended message is effectively communicated, reducing the possibility of confusion or misinterpretation. By focusing on clarity, the purpose of the memorandum can be effectively conveyed, maintaining professionalism and ensuring that the recipients are well-informed.