Nokea
When a nurse signs a consent form, which ethical principle is being observed regarding the patient?
- A. Autonomy
- B. Justice
- C. Accountability
- D. Beneficence
Correct Answer: A
Rationale: The correct answer is 'Autonomy'. Autonomy refers to the patient's right to make their own decisions, which is being honored when a nurse signs a consent form. While beneficence (Choice D) is an important ethical principle that involves acting in the patient's best interest, it is not what is being primarily observed in this instance. Justice (Choice B) refers to fairness and equal treatment and is not specifically relevant to this scenario. Accountability (Choice C) pertains to being answerable for one's actions and decisions, but again, it is not the principle directly observed in this situation. Therefore, when a nurse signs a consent form, it is the principle of autonomy that is being observed.
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Why is a pulse oximeter attached to Mr. Dizon's finger?
- A. To determine if the patient's hemoglobin level is low and if he requires a blood transfusion
- B. To check the level of the patient's tissue perfusion
- C. To measure the effectiveness of the patient's anti-hypertensive medications
- D. To detect oxygen saturation of arterial blood before symptoms of hypoxemia develop
Correct Answer: D
Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.
Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?
- A. Self-esteem disturbance
- B. Impaired urinary elimination
- C. Impaired skin integrity
- D. Risk for infection
Correct Answer: D
Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.
What effect does the use of a hot compress have, as explained to Ronnie who has been prescribed pain medication?
- A. It produces an anesthetic effect
- B. It increases nutrition in the blood to promote wound healing
- C. It increases oxygenation to the injured tissues for better healing
- D. It induces vasoconstriction to prevent infection
Correct Answer: A
Rationale: The correct answer is A: 'It produces an anesthetic effect.' Hot compresses can help alleviate pain by producing an anesthetic effect, which numbs the area. Choice B is incorrect because a hot compress does not directly increase nutrition in the blood to promote wound healing. Choice C is also incorrect because a hot compress primarily aids in pain relief rather than increasing oxygenation to the tissues for enhanced healing. Choice D is incorrect because hot compresses typically lead to vasodilation, not vasoconstriction, which aids in promoting blood flow rather than preventing infection. Safe and effective patient care relies on actions based on established nursing protocols that consider both the immediate and long-term needs of the patient.
During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?
- A. Stay with the client for the first 15 minutes of blood administration
- B. Stay with the client for the entire period of blood administration
- C. Run the infusion at a faster rate during the first 15 minutes
- D. Inform the client to notify the staff immediately for any adverse reaction
Correct Answer: A
Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.
What is the term for a state of disequilibrium wherein a person cannot readily solve a problem or situation using their usual coping mechanisms?
- A. Crisis
- B. Mental health
- C. Mental illness
- D. Stress
Correct Answer: A
Rationale: In psychological terms, a 'Crisis' refers to a state of disequilibrium wherein a person cannot readily solve a problem or situation even by using his usual coping mechanisms. This is different from 'Mental Illness' (Choice C) which is a more general term for a wide range of mental health conditions that affect mood, thinking and behavior. 'Mental Health' (Choice B) is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Finally, 'Stress' (Choice D) is a state of mental or emotional strain or tension resulting from adverse or demanding circumstances, but it does not necessarily disrupt equilibrium to the extent that usual coping mechanisms are ineffective, unlike 'Crisis'.