Nokea
The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
- A. Measuring capillary blood glucose level
- B. Measuring nasoenteric tube for insertion
- C. Measuring pH in gastrointestinal aspirate
- D. Measuring the patient’s risk for aspiration
Correct Answer: A
Rationale: The correct answer is A because measuring capillary blood glucose level is a task that can be safely delegated to nursing assistive personnel. This task is within their scope of practice and does not require specialized nursing knowledge. Nursing assistive personnel can perform this task accurately with proper training and supervision.
Incorrect choices:
B: Measuring nasoenteric tube for insertion requires specialized training and assessment skills that nursing assistive personnel may not possess.
C: Measuring pH in gastrointestinal aspirate involves interpretation and clinical judgment that should be done by a licensed nurse.
D: Measuring the patient's risk for aspiration involves critical thinking and assessment skills that are beyond the scope of nursing assistive personnel.
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A patient has returned to the floor from the PACU after undergoing a suprapubic prostatectomy. The nurse notes significant urine leakage around the suprapubic tube. What is the nurses most appropriate action?
- A. Cleanse the skin surrounding the suprapubic tube.
- B. Inform the urologist of this finding.
- C. Remove the suprapubic tube and apply a wet-to-dry dressing.
- D. Administer antispasmodic drugs as ordered.
Correct Answer: B
Rationale: The correct answer is B: Inform the urologist of this finding. In this scenario, significant urine leakage around the suprapubic tube indicates a potential issue with the tube placement or functioning. It is crucial to involve the urologist, who is the specialist managing the patient's urological interventions, to assess and address the cause of the leakage promptly. This action ensures timely and appropriate intervention to prevent complications such as infection or further damage.
Choice A is incorrect because simply cleansing the skin does not address the underlying issue of urine leakage. Choice C is incorrect and potentially harmful as removing the suprapubic tube without professional assessment can lead to serious complications. Choice D is incorrect as administering antispasmodic drugs may not be the appropriate action without further evaluation by the urologist.
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurses choice of educational interventions?
- A. Many older adults do not see themselves as being at risk for HIV infection.
- B. Many older adults are not aware of the difference between HIV and AIDS.
- C. Older adults tend to have more sex partners than younger adults.
- D. Older adults have the highest incidence of intravenous drug use.
Correct Answer: A
Rationale: The correct answer is A because it addresses the key issue of perception of risk among older adults. Many older adults may not perceive themselves as being at risk for HIV infection due to misconceptions or lack of awareness. This principle guides the nurse to tailor educational interventions to address this specific barrier. Choices B, C, and D are incorrect as they do not directly address the perception of risk among older adults. Older adults' awareness of HIV/AIDS, number of sex partners, or incidence of intravenous drug use are not the primary factors influencing their perception of HIV risk.
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?
- A. Position in semi-Fowler’s.
- B. Flex head with chin tuck.
- C. Place food on left side.
- D. Offer fruit juice.
Correct Answer: B
Rationale: The correct answer is B: Flex head with chin tuck. This position helps prevent aspiration by closing off the airway during swallowing. Flexing the head and tucking the chin promotes safe swallowing and reduces the risk of choking. Placing food on the left side (choice C) is not relevant to addressing the patient's symptoms. Positioning in semi-Fowler's (choice A) may not directly address the swallowing difficulty. Offering fruit juice (choice D) does not address the patient's specific feeding needs and may not be safe if the patient has swallowing difficulties.
A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
- A. Use of oral contraceptives increases the risk of ovarian cancer.
- B. Most cases of ovarian cancer are attributed to tobacco use.
- C. Most cases of ovarian cancer are considered to be random, with no obvious causation.
- D. The majority of women who get ovarian cancer have a family history of the disease.
Correct Answer: C
Rationale: Step 1: The nurse should inform the patient that most cases of ovarian cancer are considered to be random, with no obvious causation. This is the correct answer because the exact cause of ovarian cancer is not well understood, and the majority of cases are not linked to specific risk factors.
Step 2: Choice A is incorrect because the use of oral contraceptives actually decreases the risk of ovarian cancer.
Step 3: Choice B is incorrect because tobacco use is not a major risk factor for ovarian cancer. It is primarily associated with lung and other types of cancer.
Step 4: Choice D is incorrect because while a family history of ovarian cancer can increase the risk, the majority of women diagnosed with ovarian cancer do not have a family history of the disease.
A patient has returned to the post-surgical unit after vulvar surgery. What intervention should the nurse prioritize during the initial postoperative period?
- A. Placing the patient in high Fowlers position
- B. Administering sitz baths every 4 hours
- C. Monitoring the integrity of the surgical site
- D. Avoiding analgesics unless the patients pain is unbearable
Correct Answer: C
Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.