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The nurse preceptor and a new graduate nurse on the surgical unit are performing preoperative assessments on a group of patients. What statement by the graduate nurse requires the preceptor to intervene?
- A. I am sure everything will be fine; you have nothing to worry about.
- B. When you return from surgery, you'll need to cough and deep breathe.
- C. Many people on this unit have had that procedure with good success.
- D. You seem fearful, can I answer any questions about the procedure?
Correct Answer: A
Rationale: Telling a patient that everything will be fine is a clich?©. This statement gives false assurance and may give the patient the impression that the nurse is dismissive of a patient's concerns or condition.
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A toddler with vomiting, diarrhea, and dehydration is being seen at an acute care center. During the admission interview, what question will the nurse ask the parents to elicit the most useful information?
- A. Watching your child vomiting and in discomfort must have been scary.
- B. This started yesterday, correct?
- C. Has this child had anything to drink?
- D. Could you tell me the color and approximate amount of the vomiting?
Correct Answer: D
Rationale: Using a clarifying question or comment allows the nurse to gain an understanding of the parents' observations, avoiding misunderstandings that could lead to an inappropriate nursing diagnosis. A reflective question technique involves repeating what the person has said or describes the person's feelings. Assertive questions are direct, demonstrating the ability to stand up for self or others, using open and honest communication. Open-ended questions encourage free verbalization and expression of what the parents believe to be true.
A nurse enters a patient's room and finds them vomiting bright red blood. After taking vital signs, the nurse communicates the event to the health care provider using the SBAR format. Which information will the nurse include in the 'A' portion of the SBAR communication?
- A. Admitted with peptic ulcer and bleeding disorder
- B. Found vomiting in bathroom
- C. Anti-ulcer medication recommendation
- D. Vital signs, oxygen saturation, bright red emesis
Correct Answer: D
Rationale: The SBAR method is used to improve hand-off communication. SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a clear, structured, and easy to use framework. Vital signs, oxygen saturation, and the presence of emesis and its color are assessments.
A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and grunting sounds. Based on these nonverbal cues, what action will the nurse take next?
- A. Assess for pain and the need for analgesia.
- B. Ask the patient if they feel anxious.
- C. Offer to sit with the patient and listen to their feelings.
- D. Suggest the patient increase their fluid intake to prevent constipation.
Correct Answer: A
Rationale: A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and grunting sounds is most likely communicating pain. The nurse should clarify this nonverbal behavior.
A nursing student is preparing to administer morning care to a patient. What question by the student is most important to ask?
- A. Would you prefer a bath or a shower?
- B. May I help you with a bed bath now or later this morning?
- C. I will be giving you your bath. Do you use soap or shower gel?
- D. I prefer a shower in the evening. When would you like your bath?
Correct Answer: B
Rationale: The nurse should ask permission to assist the patient with a bath. This allows for patient preferences and consent for care that involves entering the patient's personal space.
A primary nurse is preparing a discharge plan for a patient who has been hospitalized following a double mastectomy. Which statement is most appropriate for the nurse to use in the termination phase of the therapeutic relationship?
- A. Let's review the progress you've made in meeting your goals.
- B. I'd like to review your medication schedule with you.
- C. I need to document today's teaching session in the electronic health record.
- D. Should we include your family in today's session?
Correct Answer: A
Rationale: The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning correlates with the termination phase of a therapeutic relationship and the progress toward the patient's goals are reviewed.