Nokea
The nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for?
- A. Loss of weight
- B. Loss of bone mass
- C. Loss of hope
- D. Loss of strength
Correct Answer: C
Rationale: When a patient is immobile, the nurse should assess for psychosocial aspects, including a loss of hope and increased risk of depression. While issues like weight loss (choice A), loss of bone mass (choice B), and loss of strength (choice D) can also occur due to immobility, the primary concern in this scenario is the patient's mental and emotional well-being, making 'Loss of hope' the correct answer.
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A nurse is caring for a patient who has just returned from surgery. What is the nurse's priority action?
- A. Monitor the patient's pain level.
- B. Assess the patient's vital signs.
- C. Assess the surgical incision site.
- D. Position the patient in a high Fowler's position.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's vital signs. Assessing vital signs is crucial as it helps to detect any early signs of complications such as bleeding, shock, or changes in oxygenation. Monitoring the patient's pain level (Choice A) is important but assessing vital signs takes precedence. While assessing the surgical incision site (Choice C) is essential, ensuring the patient's physiological stability through vital sign assessment is the priority. Positioning the patient in a high Fowler's position (Choice D) may be necessary for comfort but does not address the immediate need to assess the patient's condition post-surgery.
The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?
- A. Reevaluate the temperature and white blood cell count in 4 hours.
- B. Check which solution was used for skin preparation in surgery.
- C. Plan to change the surgical dressing during the shift.
- D. Utilize SBAR to notify the primary health care provider.
Correct Answer: D
Rationale: The patient is showing signs of a possible surgical site infection, including redness, purulent drainage, tenderness, elevated temperature, and increased white blood cell count. These symptoms suggest the need for immediate action to address a potential complication. Utilizing SBAR to notify the primary health care provider is crucial as it allows for effective communication of the patient's condition and the need for further assessment and intervention. Reevaluating the temperature and white blood cell count later, checking the solution used for skin preparation, or planning to change the dressing do not address the urgent need for intervention and communication with the healthcare provider.
The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. I should call 911 if my grandchild loses consciousness.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. If my grandchild eats a plant, I should provide syrup of ipecac.
- D. The number for poison control is 800-222-1222.
Correct Answer: C
Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.
After placing the patient back in bed, what should the nurse do next?
- A. Re-assess the patient.
- B. Complete an incident report.
- C. Notify the health care provider.
- D. Do nothing, no harm has occurred.
Correct Answer: C
Rationale: After placing the patient back in bed, the nurse should notify the health care provider. This is important because the health care provider needs to be informed of the incident and assess the patient further to ensure no underlying injuries or issues exist. Re-assessing the patient is crucial but notifying the health care provider takes precedence in this situation. Completing an incident report is important for documentation purposes but not the immediate next step. Doing nothing is incorrect as there was an incident involving a fall that needs further evaluation.
A healthcare professional is reviewing the notes written by a previous shift. Which documentation reflects proper guidelines?
- A. Incomplete entries are acceptable as long as they are justified
- B. Documentation should include objective observations only
- C. Corrections in documentation should be signed and dated
- D. Entries should be modified by another healthcare professional if necessary
Correct Answer: B
Rationale: The correct answer is B. Proper documentation should include objective observations and detailed notes to ensure continuity of care. Choice A is incorrect because incomplete entries can lead to gaps in information and compromise patient care. Choice C is not completely accurate as corrections should be made in a manner that does not obscure the original entry but does not necessarily require a signature. Choice D is incorrect as entries should ideally be corrected by the original author to maintain accountability and accuracy.