Nokea
To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select allthat apply.)
- A. Allows fasting on Yom Kippur for a Jewish patient
- B. Allows caffeine drinks for a Mormon patient
- C. Serves no ham products to a Muslim patient
- D. Serves kosher foods to a Christian patient
Correct Answer: A
Rationale: A. Allowing fasting on Yom Kippur for a Jewish patient demonstrates culturally sensitive care by respecting and accommodating the religious practices of the patient. Yom Kippur is an important day of fasting and repentance in the Jewish faith, and by allowing the patient to observe this practice, the nurse shows understanding and support.
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The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
- A. Teach the patient about the risks of ototoxic medications.
- B. Instruct the patient to protect the ear from water for several weeks.
- C. Teach the patient to remove cerumen safely at least once per week.
- D. Instruct the patient to protect the ear from temperature extremes until healing is complete.
Correct Answer: B
Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.
An oncology patient will begin a course of chemotherapy and radiation therapy for the treatment of bone metastases. What is one means by which malignant disease processes transfer cells from one place to another?
- A. Adhering to primary tumor cells
- B. Inducing mutation of cells of another organ
- C. Phagocytizing healthy cells
- D. Invading healthy host tissues
Correct Answer: D
Rationale: Malignant disease processes transfer cells from one place to another primarily through the invasion of healthy host tissues. Cancer cells have the ability to break away from the primary tumor site and invade nearby healthy tissues. Once invasive cancer cells find their way into blood vessels or lymphatics, they can be carried to distant sites in the body where they can form new tumors, establish metastases, and spread the disease. This invasive property of cancer cells underlies the ability of cancer to spread throughout the body, a process known as metastasis. Commanding the cells to appear to adhere to primary tumor cells, inducing mutation of cells of another organ, or phagocytizing healthy cells are not mechanisms by which malignant disease processes transfer cells from one place to another.
The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?
- A. Run lipids for no longer than 24 hours.
- B. Take down a running bag of TPN after 36 hours.
- C. Clean injection port with alcohol 5 seconds before and after use.
- D. Wear a sterile mask when changing the central venous catheter dressing.
Correct Answer: D
Rationale: When caring for a patient receiving total parenteral nutrition (TPN), it is crucial to maintain strict aseptic technique to prevent infection. Wearing a sterile mask when changing the central venous catheter dressing helps to reduce the risk of introducing pathogens into the catheter site, which can lead to serious bloodstream infections. It is essential to use sterile gloves, a sterile mask, and to assess the insertion site for any signs or symptoms of infection during central venous catheter dressing changes. Additionally, to prevent infection, TPN infusion tubing should be changed every 24 hours, and no single container of TPN should be hung for longer than 24 hours, with lipids not running for longer than 12 hours.
A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transuretheral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action?
- A. Closely monitoring the input and output of the bladder irrigation system
- B. Administering parenteral nutrition and fluids as ordered
- C. Monitoring the patients level of consciousness and skin turgor
- D. Scanning the patients bladder for retention every 2 hours
Correct Answer: A
Rationale: The nurse should prioritize closely monitoring the input and output of the bladder irrigation system to assess for the risk of imbalanced fluid volume in a patient following a transuretheral resection of the prostate. Bladder irrigation is a common postoperative procedure used to prevent blood clots and help with healing. Monitoring the input and output of the bladder irrigation system is crucial in assessing the patient's fluid balance. Changes in the output may indicate bleeding or retention, which can lead to imbalanced fluid volume. By closely monitoring the bladder irrigation system, the nurse can promptly identify any issues and intervene accordingly to prevent further complications. Monitoring the patient's level of consciousness, skin turgor, and scanning for bladder retention are important assessments, but for this specific situation, monitoring the bladder irrigation system is the priority to assess for imbalanced fluid volume.
A nurse is assessing population groups for therisk of suicide requiring medical attention. Which group should the nurse monitormostclosely?
- A. Young bisexuals
- B. Young caucasians
- C. Asian Americans
- D. African-Americans.
Correct Answer: A
Rationale: Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide attempts, and substance use disorders. In particular, bisexual youth are at a higher risk than their straight peers for experiencing mental health issues and suicide attempts that require medical attention. Studies have shown that young bisexuals are four times more likely than their straight counterparts to make suicide attempts that necessitate medical intervention. Therefore, it is crucial for the nurse to closely monitor this population group for signs of suicidal behavior and provide the necessary support and interventions to prevent such tragedies.