Nokea
What nursing intervention would the nurse include in the preoperative care plan for a patient scheduled for an outpatient lumpectomy of a fibroadenoma?
- A. Administer pain and antiemetic medications.
- B. Help the patient arrange for a cab home after the procedure.
- C. Advise the patient to avoid food or drink for 2 hours before surgery.
- D. Review discharge instructions.
Correct Answer: C
Rationale: It is essential to advise the patient to avoid food or drink for at least 2 hours before surgery to reduce the risk of aspiration during the procedure. An empty stomach helps prevent vomiting and aspiration of stomach contents that could potentially lead to respiratory complications during the surgical procedure. This is a crucial preoperative nursing intervention to ensure patient safety and preparation for the lumpectomy surgery. Administering pain and antiemetic medications, arranging for transportation home, and reviewing discharge instructions are important aspects of care but do not directly impact the patient's safety during the procedure like fasting before surgery does.
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The nurse is providing education to the patient that is receiving a bisphosphate medication for osteoporosis. Which instructions should the nurse include in the teaching plan to reduce side effects and enhance absorption while taking bisphosphates? Select all that apply.
- A. Take the medication with a small meal at the same time
- B. Take the medication with at least 8 oz. of water.
- C. Remain upright for at least 30 minutes after taking a dos
- D. Take the medication on an empty stomach
Correct Answer: A
Rationale: A. Take the medication with a small meal at the same time: Bisphosphonate medications should be taken with a small meal rather than on an empty stomach to enhance absorption and reduce the risk of gastrointestinal side effects.
Which step of the nursing process is being used when the nurse decides whether an ethical dilemma exists?
- A. Analysis
- B. Planning
- C. Evaluation
- D. Assessment
Correct Answer: A
Rationale: Analysis is the step of the nursing process being used when the nurse decides whether an ethical dilemma exists. During the analysis step, the nurse gathers and interprets data to make sense of a clinical situation. In the case of ethical dilemmas, the nurse would assess the situation, gather relevant information, and analyze it to determine if there is a conflict in values, beliefs, or principles, which would classify it as an ethical dilemma. Once the nurse identifies the existence of an ethical dilemma through analysis, they can then move on to the planning phase to decide on a course of action.
Which nursing intervention is written correctly?
- A. Force fluids as necessary.
- B. Observe interaction with the infant.
- C. Encourage turning, coughing, and deep breathing. N R I G B.C M U S N T O
- D. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
Correct Answer: D
Rationale: The correct nursing intervention that is written correctly is option D. The intervention "Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM" is clear, specific, and provides a specific time frame for the activity. It is important in nursing documentation to be precise and clearly state the details of the intervention to ensure effective communication among healthcare team members. This intervention also specifies the frequency and duration of the ambulation activity, which helps in ensuring continuity of care and proper execution of the intervention for the patient.
The nurse is providing preoperative education on the laparoscope-assisted vaginal hysterectomy. Which statement by the patient verifies understanding of the procedure?
- A. I will use a mild douche solution to keep the surgical area clean.
- B. I'm relieved that I won't have any visible scars on my abdomen.
- C. I understand that there will be some light vaginal bleeding for several days.
- D. I understand that I must remain on bedrest until cleared by the surgeon.
Correct Answer: B
Rationale: The correct statement by the patient that demonstrates understanding of the laparoscope-assisted vaginal hysterectomy procedure is "I'm relieved that I won't have any visible scars on my abdomen." This is a relevant and accurate statement as the procedure involves minimal scarring due to the use of small incisions in the abdomen rather than a large incision. It shows understanding of one of the benefits of this surgical approach. The other statements are not accurate or relevant to the procedure.
Which nursing intervention is an independent function of the professional nurse?
- A. Administering oral analgesics
- B. Requesting diagnostic studies
- C. Teaching the patient perineal care
- D. Providing wound care to a surgical incision
Correct Answer: A
Rationale: Administering oral analgesics is an independent function of the professional nurse. Independent nursing interventions are those that a nurse is licensed to initiate based on their knowledge and skills without needing an order from a healthcare provider. Nurses are educated and trained in medication administration, including oral analgesics, and can independently assess the need for and safely administer them within their scope of practice. While requesting diagnostic studies, teaching perineal care, and providing wound care are essential nursing interventions, they typically require some form of healthcare provider's order or supervision, making them more interdependent activities.