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To collect timely, specific information, the nurse is most likely to ask which of the following questions?
- A. Would you describe what you are feeling?
- B. How are you today?
- C. What would you like to talk about?
- D. Where does it hurt?
Correct Answer: A
Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues. Choices B and C are more likely to yield general, nonspecific information. Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'
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For a patient who is blood type AB, which blood product can they receive?
- A. Plasma from a type B donor
- B. Whole blood from a type A donor
- C. Packed RBCs from a type O donor
- D. All of the above
Correct Answer: C
Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.
A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?
- A. Run the urine on the hand-held glucometer.
- B. Have another MA perform a repeat dipstick test.
- C. Run a Clinitest.
- D. Run an Acetest.
Correct Answer: C
Rationale: To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n
Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n
Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n
Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.
During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?
- A. Formulate a nursing diagnosis of impaired gas exchange
- B. Record in the medical record the distance a client ambulates in the hall
- C. Write individualized nursing orders in the care plan
- D. Compare client responses to the desired outcomes for pain relief
Correct Answer: B
Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.
When printing out an EKG, a nurse notices that the QRS complexes are extremely small. What should be the next step?
- A. Alert the physician immediately as this is a sign of impending cardiac arrest.
- B. Check to see that all leads are attached and rerun the EKG.
- C. Increase the sensitivity control to 20 mm deflection.
- D. Decrease the run speed to 50.
Correct Answer: C
Rationale: Increasing the sensitivity control to 20 mm deflection will double the sensitivity, allowing for better observation of the small QRS complexes. This step is crucial in obtaining a clearer EKG reading. Choice A is incorrect because small QRS complexes do not necessarily indicate impending cardiac arrest; it's more likely a technical issue. Choice B is not the first step to take when small QRS complexes are observed; it's important to adjust the settings first. Choice D is incorrect because decreasing the run speed to 50 is not the appropriate action for this situation; adjusting the sensitivity control is more relevant to improve the visualization of the complexes.
During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?
- A. Ask the patient how he or she is feeling.
- B. Document the findings in the patient's record.
- C. Wait 10 minutes and auscultate the sound again.
- D. Ask another nurse to double-check the finding.
Correct Answer: D
Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.