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The nurse is assessing the patient for respiratory complications of immobility. What action should the nurse take?
- A. Auscultate the entire lung region to assess lung sounds.
- B. Assess the patient at least every 4 hours.
- C. Focus auscultation on the upper lung fields.
- D. Inspect chest wall movements primarily during the expiratory cycle.
Correct Answer: A
Rationale: Auscultating the entire lung region is the most appropriate action when assessing a patient for respiratory complications related to immobility. This approach helps the nurse identify any abnormalities in lung sounds, such as diminished breath sounds or the presence of secretions. Assessing the patient at regular intervals (choice B) is important but does not specifically address the respiratory assessment needed in this situation. Focusing auscultation on the upper lung fields (choice C) may miss potential issues in other areas. Inspecting chest wall movements primarily during the expiratory cycle (choice D) is not the most effective way to assess lung sounds and identify respiratory complications.
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A patient with a left arm fracture reports severe pain unrelieved by medication. What should the nurse assess for?
- A. Check for compartment syndrome
- B. Increase the pain medication
- C. Prepare the patient for surgery immediately
- D. Administer a sedative to calm the patient
Correct Answer: A
Rationale: Correct answer: When a patient with a left arm fracture reports severe pain unrelieved by medication, the nurse should assess for compartment syndrome. Compartment syndrome is a condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. It is a surgical emergency that requires immediate intervention. Choice B is incorrect because simply increasing pain medication without identifying the cause of the unrelieved pain may mask symptoms of a serious issue like compartment syndrome. Choice C is incorrect as surgery would only be necessary if compartment syndrome is confirmed. Choice D is incorrect as administering a sedative does not address the underlying issue of unrelieved pain and may delay appropriate treatment.
When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?
- A. Proceed with the surgery and document the refusal.
- B. Ask the patient for permission to secure the jewelry safely.
- C. Tape the jewelry to the patient's body during surgery.
- D. Tell the patient they must remove the jewelry for safety reasons.
Correct Answer: B
Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.
Which finding in a postoperative patient requires immediate intervention by the nurse?
- A. Heart rate of 88 beats per minute.
- B. Blood pressure of 130/80 mmHg.
- C. Crackles heard in the lung bases.
- D. Oxygen saturation of 88% on room air.
Correct Answer: D
Rationale: In a postoperative patient, an oxygen saturation level of 88% on room air indicates a significant drop below the normal range, suggesting potential respiratory distress. This finding requires immediate intervention by the nurse to ensure the patient receives adequate oxygenation. A heart rate of 88 beats per minute is within the normal range, making it a less concerning finding. A blood pressure of 130/80 mmHg falls within the normal range for blood pressure and does not require immediate intervention. Crackles heard in the lung bases may indicate fluid accumulation but may not always require immediate intervention unless accompanied by other concerning signs or symptoms.
A nurse witnesses a colleague administering the wrong IV solution to a client. What should the nurse do first?
- A. Complete an incident report.
- B. Ask the colleague if they intend to report the error.
- C. Call the healthcare provider to notify them of the error.
- D. Notify the supervisor about the situation.
Correct Answer: B
Rationale: The correct first step for the nurse to take in this situation is to ask the colleague if they intend to report the error. It is important to address the error promptly and directly with the colleague involved to ensure that the appropriate actions are taken to correct the mistake and prevent harm to the client. Completing an incident report, calling the healthcare provider, or notifying the supervisor can be done after discussing the error with the colleague. Immediate communication with the colleague directly involved in the error is crucial to address the situation effectively.
A client expresses concern about hair loss during chemotherapy. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy begins.
- B. Offer resources for wigs and head coverings.
- C. Assure the client that hair loss will be minimal.
- D. Ignore the client's concerns about hair loss.
Correct Answer: B
Rationale: During chemotherapy, hair loss is a common side effect. Offering resources for wigs and head coverings can help the client cope with this change in appearance, maintain self-esteem, and feel more comfortable during the process. Encouraging the client to cut their hair short does not address the emotional impact of hair loss and may not be the client's preference. Assuring the client that hair loss will be minimal may provide false hope as significant hair loss is a common occurrence. Ignoring the client's concerns is not appropriate and goes against the principles of providing holistic and compassionate care.