Nokea
The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
- A. Protocols are guidelines to follow that replace the nursing care plan. Protocols assist the clinician in making decisions and choosing interventions for specific
- B. health care problems or conditions. Protocols are policies designating each nurse’s duty according to standards of care and a
- C. code of ethics.
- D. Protocols are prescriptive order forms that help individualize the plan of care.
Correct Answer: A
Rationale: The correct answer is A because protocols are indeed guidelines that assist clinicians in decision-making and choosing interventions for specific health care problems. This definition accurately reflects the purpose and function of protocols in nursing practice.
Option B is incorrect as it describes protocols as policies related to nurses' duties and standards of care, which is more aligned with job descriptions and policies rather than protocols.
Option C is incorrect as it relates protocols to a code of ethics, which is a separate concept that guides ethical decision-making and behavior in nursing practice.
Option D is incorrect as it inaccurately describes protocols as prescriptive order forms, which are actually separate from protocols and are used for medication administration and treatment orders.
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After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C):
1. Safety first: Patient safety is the top priority in healthcare. Vital signs provide crucial information about the patient's condition.
2. Accountability: The nurse is responsible for ensuring accurate vital sign documentation. Asking the NAP to record vital signs before medication administration ensures accountability.
3. Communication: Clear communication between healthcare team members is essential to provide quality care. Asking the NAP to record vital signs promotes effective communication.
Summary of Incorrect Choices:
A (abnormal vital signs): Administering medications without knowing the patient's vital signs, especially if abnormal, can be dangerous and potentially harmful.
B (review upon return): Delaying vital sign assessment until later can lead to missed opportunities for timely intervention if the patient's condition changes.
D (omit vital signs): Neglecting vital signs based on assumption risks overlooking potential issues that could impact patient care and outcomes.
A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?
- A. “Anemia prevents your lungs from absorbing oxygen effectively.”
- B. “You do not have enough hemoglobin to carry oxygen to your tissues.”
- C. “”You don’t have enough blood to feed your cells.”
- D. “You have lost a lot of blood, and that has damaged your lungs.”
Correct Answer: B
Rationale: The correct answer is B because hemoglobin carries oxygen to the tissues, and with a low hemoglobin level of 6 g/dL, there is insufficient oxygen-carrying capacity to meet the body's needs, leading to shortness of breath (SOB). Choice A is incorrect as anemia affects oxygen transport, not absorption. Choice C is incorrect as anemia affects oxygen delivery, not nutrient delivery. Choice D is incorrect as the primary reason for SOB in this scenario is the lack of oxygen-carrying capacity due to low hemoglobin levels, not lung damage from blood loss.
The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient’s gastrointestinal tract is resuming normal function?
- A. Firm abdomen
- B. Presence of flatus
- C. Excessive thirst
- D. Absent bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Presence of flatus. This indicates normal gastrointestinal function post-bowel resection. Flatus production signifies peristalsis and passage of gas through the intestines, indicating that the bowels are working. A, firm abdomen, may indicate distention or ileus, not normal function. C, excessive thirst, is unrelated to bowel function. D, absent bowel sounds, may indicate ileus or bowel obstruction, not normal function.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Choice C:
1. Safety First: Recording vital signs is crucial for patient safety. Asking the NAP to record vital signs ensures the patient's condition is monitored before administering medications.
2. Accountability: Nurses are responsible for ensuring accurate documentation of vital signs. Asking the NAP to record them maintains accountability within the healthcare team.
3. Communication: By requesting the NAP to record vital signs, the nurse fosters effective communication and collaboration in patient care.
Summary of Other Choices:
A: Administering medications without reviewing vital signs could lead to adverse effects if there are abnormalities.
B: Reviewing vital signs upon return delays immediate action and could jeopardize patient safety.
D: Omitting vital signs neglects the essential monitoring required for patient care and could result in missed opportunities for early intervention.
The following are warning signs of cancer. Which one is not?
- A. Change In bladder and bowel habits
- B. Weight gain
- C. Indigestion or difficulty in swallowing
- D. Nagging cough or hoarseness
Correct Answer: B
Rationale: The correct answer is B, weight gain, as it is not typically considered a warning sign of cancer. Changes in bladder and bowel habits (A), indigestion or difficulty in swallowing (C), and a nagging cough or hoarseness (D) are commonly associated with various types of cancer. Weight gain is more commonly linked to factors such as diet, exercise, and hormonal imbalances rather than cancer. It is important to be vigilant about the other warning signs and seek medical attention if any of those symptoms persist.