The team leader is reviewing what the HCP has just prescribed for Mr. N (non-Hodgkin lymphoma). What will the team leader question?
- A. Administer filgrastim 5 mcg/kg subcutaneously every day
- B. Catheterize to obtain a urinalysis specimen.
- C. Flush the IV saline lock every shift.
- D. Monitor vital signs every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer filgrastim 5 mcg/kg subcutaneously every day. The rationale for this is that filgrastim is a medication commonly prescribed for patients with non-Hodgkin lymphoma to stimulate the production of white blood cells. Therefore, the team leader should question the dosage, route of administration, and frequency to ensure it aligns with the prescribed treatment plan.
Incorrect choices:
B: Catheterize to obtain a urinalysis specimen - This is not relevant to the prescribed treatment for non-Hodgkin lymphoma.
C: Flush the IV saline lock every shift - Important for maintaining IV access but not directly related to the prescribed medication.
D: Monitor vital signs every 4 hours - Monitoring vital signs is important but not the primary concern when reviewing a prescribed medication for non-Hodgkin lymphoma.
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As an experienced staff nurse, you have been asked to create a teaching guide for nursing orientation on respect. Accessing the list from Ehow about being genuine, you would include all of the following. (Select all that apply)
- A. Acting natural around others
- B. Listening when others are speaking
- C. Denying your mistakes
- D. Compliment only when you sincerely mean it
Correct Answer: A
Rationale: Step 1: Being genuine means acting natural around others, which fosters trust and respect in relationships.
Step 2: Acting natural promotes authenticity and conveys sincerity, enhancing communication and connection.
Step 3: Listening when others are speaking is also crucial for respect, as it shows empathy and understanding.
Step 4: Denying mistakes goes against respect and honesty, leading to mistrust and lack of credibility.
Step 5: Complimenting only when sincere is important, but not directly related to being genuine in this context.
The nurse is aware that the purpose of therapeutic communication is to:
- A. gather as much information as possible about the patient's problem.
- B. direct the patient to communicate about his deepest concerns.
- C. focus on the patient and the patient needs to facilitate interaction.
- D. gain specific medical information and history of illness.
Correct Answer: C
Rationale: The correct answer is C because therapeutic communication aims to focus on the patient and their needs to facilitate a therapeutic interaction. This involves active listening, empathy, and creating a supportive environment for the patient to express their thoughts and feelings. Gathering information (choice A) is important but not the sole purpose of therapeutic communication. Directing the patient to communicate about deepest concerns (choice B) may not always be appropriate or helpful. Lastly, gaining specific medical information and history of illness (choice D) is part of a comprehensive assessment but not the primary goal of therapeutic communication.
The nurse chooses to use touch in the nurse-patient relationship because touch:
- A. can convey caring and support when words are difficult.
- B. should be avoided because of problems of cultural misinterpretation.
- C. is appropriate only in special circumstances, such as with young children.
- D. is a nursing intervention of choice in almost all situations.
Correct Answer: A
Rationale: The correct answer is A because touch can convey caring and support when words are difficult, enhancing the nurse-patient relationship. This is supported by research showing the positive impact of touch in providing comfort and building trust. Choice B is incorrect as cultural differences can be addressed through communication and understanding. Choice C is incorrect because touch can be appropriate in various situations beyond just young children. Choice D is incorrect as touch should be used judiciously based on individual preferences and boundaries.
Which nonverbal action(s) would be consistent with an assertive style of communication? (Select all that apply)
- A. Relaxed posture
- B. Established eye contact
- C. Hands placed on hips
- D. Distant, soft voice
Correct Answer: A
Rationale: The correct answer is A (Relaxed posture) because assertiveness is about expressing oneself confidently while respecting others. A relaxed posture conveys confidence and self-assurance. Established eye contact (B) is also consistent with assertiveness, showing engagement and sincerity. Choices C (Hands placed on hips) and D (Distant, soft voice) are more indicative of aggression or passivity, respectively, rather than assertiveness. Placing hands on hips can come across as confrontational, while a distant, soft voice lacks the firmness and clarity associated with assertive communication.
Which assessment finding for Mr. L (tracheostomy and partial laryngectomy) would be of greatest concern?
- A. Pulsation of the tracheostomy tube in synchrony with the heartbeat
- B. Increased secretions in and around the tracheostomy
- C. Increased coughing, with difficulty in expectorating secretions
- D. Presence of food particles in tracheal secretions
Correct Answer: A
Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety.
Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding.
Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding.
Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.
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