Nokea
Right after endorsement and during the rounds, the incoming nurse observes that the IV fluid is at 800 cc level and not 400cc, as endorsed. What is the CORRECT information that she will chart?
- A. Anything goes, nobody reads the charting anyway.
- B. Record the 400 cc.
- C. Chart that she received 800
- D. Refer to the Head Nurse on what to do.
Correct Answer: C
Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.
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While preparing the surgical site, the nurse notices that the skin preparation solution has expired. What should the nurse do?
- A. Use the expired solution as it is still effective
- B. Document the expiration date in the patient's chart
- C. Discard the expired solution and obtain a new one
- D. Dilute the solution with sterile water to extend its shelf life
Correct Answer: C
Rationale: Using an expired skin preparation solution can compromise the safety and effectiveness of the surgical site cleansing. Expired solutions may have reduced efficacy or could cause adverse reactions due to chemical breakdown over time. Therefore, it is essential for the nurse to discard the expired solution and obtain a new one to ensure proper sanitation and reduce the risk of complications during the surgical procedure. It is important to adhere to proper protocols and guidelines in healthcare settings to maintain patient safety and optimal outcomes.
Which should be emhpasize by the nurse in her health teachings
- A. Jogging a mile a day
- B. Vigourous exercise
- C. No need to diet
- D. Weight reduction
Correct Answer: D
Rationale: Weight reduction is the most important focus in the health teachings provided by the nurse. Maintaining a healthy weight is crucial for overall well-being and can significantly reduce the risk of various health conditions such as heart disease, diabetes, and certain cancers. By emphasizing weight reduction, the nurse can help improve the patient's overall health and quality of life. Jogging a mile a day and vigorous exercise are beneficial for weight management, but it is important to address the root cause of potential health problems which in this case may be excess weight. Moreover, emphasizing the importance of weight reduction does not necessarily mean encouraging extreme dieting; instead, it involves promoting a balanced and healthy approach to eating and physical activity.
A patient presents with recurrent episodes of epistaxis, gum bleeding, and easy bruising. Laboratory tests reveal prolonged bleeding time, normal platelet count, and normal PT and aPTT. Which of the following conditions is most likely to cause these findings?
- A. Von Willebrand disease
- B. Glanzmann thrombasthenia
- C. Hemophilia A
- D. Bernard-Soulier syndrome
Correct Answer: A
Rationale: The clinical presentation of recurrent episodes of epistaxis, gum bleeding, and easy bruising, along with laboratory findings of prolonged bleeding time, normal platelet count, and normal coagulation studies (PT and aPTT) are highly suggestive of Von Willebrand disease. Von Willebrand disease is the most common inherited bleeding disorder and is characterized by a deficiency or dysfunction of von Willebrand factor (vWF), which plays a key role in platelet adhesion and aggregation. The prolonged bleeding time is due to impaired platelet adhesion to the damaged vessel wall in the absence of functional vWF. Normal platelet count and normal PT/aPTT help differentiate Von Willebrand disease from other bleeding disorders such as hemophilia and platelet function disorders like Glanzmann thrombasthenia and Bernard-Soulier syndrome.
Nurses may be privy to very personal information of patients and should make every effort to make it confidential, otherwise she can be charged of ______.
- A. negligence
- B. invasion of privacy
- C. malpractice
- D. defamation
Correct Answer: B
Rationale: Nurses are bound by strict confidentiality and privacy regulations in their profession. If a nurse fails to keep a patient's personal information confidential and discloses it without authorization, they can be charged with invasion of privacy. Invasion of privacy is the wrongful intrusion into a person's private affairs without their consent, and it is a serious violation of ethical and legal standards in healthcare. Nurses must always prioritize patient confidentiality to maintain trust and uphold ethical standards in their practice.
Her diagnosis of obsessive-compulsive disorder constantly does repetitive cleaning. The nurse knows that this behavior is probably MOST basically, an attempt to _______.
- A. Decrease the anxiety to a tolerable level
- B. Focus attention on non-threatening tasks
- C. Control others
- D. Decrease time available for interaction with people
Correct Answer: A
Rationale: The behavior of repetitive cleaning in someone diagnosed with obsessive-compulsive disorder is likely an attempt to decrease the anxiety to a tolerable level. People with OCD often engage in compulsive behaviors, such as cleaning, in an effort to alleviate the distress and anxiety caused by obsessive thoughts. This repetitive action provides a sense of control and temporary relief from the anxiety associated with their obsessive thoughts. By engaging in cleaning rituals, individuals with OCD can try to reduce their anxious feelings and create a sense of order and cleanliness in their environment.