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When an office nurse asks the patient to repeat information that he has just given to the patient over the telephone, the nurse is:
- A. testing the patient's intelligence and memory.
- B. acting in a cautious way to avoid charges of negligence.
- C. verifying that the patient understands the information.
- D. saving the extra time it would take to mail the information. Obtaining feedback from a patient to ascertain that the patient understands instructions is an important part of the communication process, especially over the phone, when the nurse does not have nonverbal cues.
Correct Answer: C
Rationale: The correct answer is C because asking the patient to repeat the information verifies their understanding. This is crucial in healthcare to ensure accurate communication and patient safety. Choice A is incorrect as it focuses on intelligence rather than comprehension. Choice B is incorrect as it assumes the nurse is motivated by avoiding negligence rather than patient care. Choice D is incorrect as saving time should not compromise patient understanding.Verifying patient comprehension fosters effective communication and prevents errors.
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Mr. U (pulmonary resection) has developed a tension pneumothorax. He is currently receiving high-flow oxygen via nonrebreather mask but continues to experience respiratory distress. What is the priority action?
- A. Remove the occlusive dressing around the chest wound.
- B. Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
- C. Initiate cardiopulmonary resuscitation (CPR).
- D. Call for the crash cart and intubation equipment.
Correct Answer: B
Rationale: The correct answer is B: Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
Rationale:
1. Tension pneumothorax is a life-threatening emergency where air accumulates in the pleural space, causing lung collapse and increased pressure in the chest.
2. The standard treatment for tension pneumothorax is needle thoracostomy, which involves inserting a large-bore needle into the chest to release the trapped air.
3. In this scenario, Mr. U is in respiratory distress despite receiving high-flow oxygen, indicating a significant problem with ventilation that requires immediate intervention.
4. Performing a needle thoracotomy will rapidly decompress the tension pneumothorax, relieving pressure on the heart and lungs, and improving respiratory function.
5. This action takes precedence over other options such as removing the occlusive dressing, initiating CPR, or calling for intubation equipment, as immediate decompression is crucial in managing tension pneumoth
While admitting a patient to the medical unit, the nurse should take which action?
- A. Demonstrate human caring by hugging the patient for brief intervals.
- B. Disclose shared intimate details with other healthcare providers.
- C. Maintain a physical distance of at least 3 to 4 feet at all times.
- D. Develop the plan of care and measurable objectives with the patient.
Correct Answer: D
Rationale: The correct answer is D because developing a plan of care and measurable objectives with the patient promotes patient-centered care, encourages collaboration, and ensures the patient's active involvement in their own care. This approach respects the patient's autonomy and preferences, fosters shared decision-making, and enhances treatment adherence.
A: Demonstrating human caring by hugging the patient may not be appropriate as it can violate professional boundaries and personal space.
B: Disclosing shared intimate details with other healthcare providers breaches patient confidentiality and violates privacy rights.
C: Maintaining a physical distance of at least 3 to 4 feet at all times may be necessary for infection control but does not address the core aspect of involving the patient in their care plan.
The hospital nurse educator develops an educational session for staff nurses on how to clearly record data in a patient's electronic medical record. Which key point should the nurse educator include in the teaching plan? (Select all that apply)
- A. A patient who is at high risk for falls will require more frequent documentation.
- B. The nurse should avoid labels (e.g., good, drug seeking, and lazy) to describe patients.
- C. Detailed and specific documentation is only required if a malpractice suit is expected.
- D. Each entry by the nurse in the electronic medical record should be clear and concise.
Correct Answer: A
Rationale: The correct answer is A because documenting the frequency of assessments and interventions for high-risk patients, such as those at risk for falls, is crucial for patient safety and care coordination. By documenting more frequently for high-risk patients, nurses can ensure timely interventions and prevent adverse events. This practice aligns with the principles of patient-centered care and risk management.
Choices B, C, and D are incorrect:
B: Avoiding labels in documentation is important for professionalism and ethical practice, but it is not directly related to the frequency of documentation for high-risk patients.
C: Detailed and specific documentation is required for all patients to ensure comprehensive care, not just for potential malpractice suits.
D: While clear and concise documentation is essential, this choice does not specifically address the need for more frequent documentation for high-risk patients.
The nurse cares for a patient who becomes confused and a vest restraint is applied. The nurse should take which action when notifying the patient's family?
- A. Avoid discussing the treatment plan to reduce anxiety and worry.
- B. Ask another nurse who has rapport with the family to be present.
- C. Use medical terms to demonstrate competence.
- D. Assume that the family wants a detailed explanation.
Correct Answer: B
Rationale: The correct answer is B because having another nurse who has a good relationship with the family present can help facilitate effective communication and address any concerns or questions the family may have. This approach can help build trust and provide emotional support during a potentially difficult situation.
A: Avoiding discussing the treatment plan can lead to confusion and distrust.
C: Using medical terms may confuse or intimidate the family and hinder effective communication.
D: Assuming the family wants a detailed explanation may not be accurate and can result in information overload.
The nurse is caring for a client who is diagnosed with type 1 diabetes mellitus. Which nursing action would most likely improve client compliance with the therapeutic regimen?
- A. Consistently ignore negative statements made by the client.
- B. Avoid touching the client to reduce tension and uneasiness.
- C. Focus on the physical aspects of care such as insulin administration.
- D. Listen attentively to the client's perception of having a chronic illness.
Correct Answer: D
Rationale: The correct answer is D because listening attentively to the client's perception of having a chronic illness is crucial for building trust, understanding their concerns, and fostering a therapeutic relationship. By actively listening, the nurse can address any misconceptions, provide education tailored to the client's needs, and involve the client in decision-making, ultimately improving compliance.
Choice A is incorrect as ignoring negative statements can lead to feelings of neglect and hinder communication. Choice B is incorrect as avoiding touching the client may create a barrier to building rapport. Choice C is incorrect as focusing only on physical care neglects the psychological and emotional aspects of managing a chronic condition like diabetes.