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The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)
- A. Keeping the urine collection container on ice when indicated
- B. Withholding all patient medications for the day
- C. Irrigating the sample as needed with sterile solution
- D. Testing the urine sample with a reagent strip by dipping it in the urine
Correct Answer: A
Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.
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A patients daughter has asked the nurse about helping him end his terrible suffering. The nurse is aware of the ANA Position Statement on Assisted Suicide, which clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. What does the Position Statement further stress?
- A. Educating families about the moral implications of assisted suicide
- B. Identifying patient and family concerns and fears
- C. Identifying resources that meet the patients desire to die
- D. Supporting effective means to honor the patients desire to die
Correct Answer: B
Rationale: The ANA Position Statement on Assisted Suicide stresses the importance of identifying patient and family concerns and fears. This reflects the nurse's responsibility to provide holistic care and support to patients and their families who may be struggling with end-of-life decisions. By identifying concerns and fears, the nurse can address these issues through compassionate communication, education, and appropriate interventions. This proactive approach aligns with the ethical principles of beneficence and nonmaleficence in nursing practice.
The nurse is describing theChooseMyPlateprogramto a patient. Which statement from the patient indicates successful learning?
- A. “I can use this to make healthy lifestyle food choices.”
- B. “I can use this to count specific calories of food.”
- C. “I can use this for my baby girl.”
- D. “I can use this when I am sick.”
Correct Answer: A
Rationale: This statement indicates successful learning because it acknowledges the main purpose of the ChooseMyPlate program, which is to help individuals make healthy food choices for a balanced diet and overall lifestyle. By understanding that ChooseMyPlate can guide them in making healthier food choices rather than just counting calories or using it for specific circumstances like sickness or infant care, the patient demonstrates a good grasp of the program's intended use and benefits.
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?
- A. Slight morning discharge from the eye
- B. Any appearance of redness of the eye
- C. A scratchy feeling in the eye
- D. A new floater in vision
Correct Answer: B
Rationale: Redness of the eye after cataract surgery can be a sign of infection or inflammation, which are serious complications that require immediate medical attention. Redness may be accompanied by pain, swelling, or discharge, and if left untreated, it can lead to complications that may affect the surgical outcome and the patient's vision. Therefore, it is crucial for the patient to contact the office immediately if they notice any redness in their eye following cataract surgery.
The nurse is caring for a patient who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the patients death is imminent?
- A. Mottling of the lower limbs
- B. Slow, steady pulse
- C. Bowel incontinence
- D. Increased swallowing
Correct Answer: A
Rationale: Mottling of the lower limbs is a common physical sign seen in patients approaching death. This occurs when there is poor circulation leading to a bluish or purplish discoloration of the skin, particularly on the extremities. The appearance of mottling indicates that the body is no longer able to maintain adequate blood flow to the extremities, signaling that the patient is in the final stages of life. It is a significant finding that strongly suggests imminent death in patients with terminal illness, such as in this case of a patient with terminal lung cancer who is unconscious.
An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurses most appropriate response?
- A. Ask if the patient has been using OTC vasoconstrictors.
- B. Instruct the patient to repeat the test at different times of the day when at home.
- C. Arrange for the patient to visit his ophthalmologist.
- D. Encourage the patient to adhere to his prescribed drug regimen. .
Correct Answer: C
Rationale: Distorted lines on an Amsler grid can be an indication of changes in central vision, which is commonly seen in macular degeneration. Therefore, it is crucial for the nurse to arrange for the patient to visit his ophthalmologist promptly for further evaluation and management. The ophthalmologist will be able to determine the severity of the visual changes, provide appropriate treatment options, and closely monitor the progression of macular degeneration. This proactive approach ensures that the patient receives timely and specialized care for his condition. Options A, B, and D do not directly address the urgency of the situation and the need for specialized ophthalmologic evaluation in cases of macular degeneration.