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When the nurse interacts with patients face-to-face such as in getting information during the assessment phase of the nursing process, the level of communication is which of the following?
- A. Intrapersonal
- B. Public communication
- C. Interpersonal
- D. Verbal
Correct Answer: C
Rationale: When the nurse interacts with patients face-to-face to gather information during the assessment phase of the nursing process, the level of communication is considered interpersonal. Interpersonal communication involves two or more individuals who are connected in a meaningful way. In this scenario, the nurse and the patient are engaging in a personal exchange of information, thoughts, and feelings. This type of communication is essential in building rapport, understanding the patient's needs, and providing effective care. It focuses on creating a supportive and therapeutic relationship between the nurse and the patient, which is crucial for delivering high-quality nursing care.
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The female client who is very anxious and fidgety is blowing off to much carbon dioxide develops tingling sensation of the lips and fingers and is not able to control her respirations. The MOST appropriate nursing intervention for this client is to _____.
- A. Instruct the client to blow her nose and take deep breath
- B. Administer oxygen
- C. Have the client breath into a paper bag
- D. Administer IV fluids as ordered
Correct Answer: C
Rationale: The client is experiencing symptoms of hyperventilation, a condition that occurs when there is excessive elimination of carbon dioxide from the body. Breathing into a paper bag can help by allowing the client to rebreathe carbon dioxide, which can help restore the balance of gases in the blood and alleviate the tingling sensations in the lips and fingers. This technique is commonly used to help regulate breathing in cases of hyperventilation. Administering oxygen (choice B) may not be necessary as the issue lies with an imbalance of carbon dioxide, not a lack of oxygen. Instructing the client to blow her nose and take deep breaths (choice A) may not address the underlying problem effectively. Administering IV fluids (choice D) is not relevant to the client's symptoms of hyperventilation.
The Medical Director, with the Chief Nurse and other officers, of the hospital believe that Patient Relations is important in risk management because a dissatisfied customer is likely to sue. Which is NOT the way to handle complaints?
- A. Let the patient express himself,
- B. Be sure to rebut the patient point by point.
- C. Staff should not be defensive.
- D. Listen to the patient's cue carefully.
Correct Answer: B
Rationale: Option B, "Be sure to rebut the patient point by point," is NOT the way to handle complaints. When dealing with patient complaints, it is important to take a calm and empathetic approach rather than engaging in a defensive or confrontational manner. Rebutting the patient point by point can escalate the situation and may further alienate the patient. Effective complaint management involves active listening, showing empathy, addressing concerns, and working towards a resolution that benefits both the patient and the healthcare provider.
A patient with a history of heart failure is prescribed spironolactone. Which electrolyte imbalance is the patient at risk for developing with spironolactone therapy?
- A. Hypernatremia
- B. Hyperkalemia
- C. Hypokalemia
- D. Hyponatremia
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic commonly used in the management of heart failure. One of the significant side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the bloodstream. Spironolactone works by blocking the action of aldosterone, a hormone that regulates potassium and sodium balance in the body. By inhibiting aldosterone, spironolactone reduces potassium excretion in the urine, leading to potential accumulation of potassium in the body.
What is the recommended position for a conscious patient experiencing an acute asthma exacerbation?
- A. High-Fowler's position
- B. Supine position with legs elevated
- C. Left lateral recumbent position
- D. Semi-Fowler's position
Correct Answer: A
Rationale: The recommended position for a conscious patient experiencing an acute asthma exacerbation is the High-Fowler's position. This position involves the patient sitting upright or almost upright at about a 90-degree angle. The High-Fowler's position helps improve ventilation by expanding the lungs and maximizing airflow in and out of the airways. It also reduces the work of breathing in patients with asthma by allowing gravity to assist in moving air in and out of the lungs more easily. Additionally, this position can help alleviate shortness of breath and improve oxygenation in patients experiencing an asthma exacerbation.
A patient is prescribed an opioid analgesic for postoperative pain management. Which nursing intervention is essential for preventing respiratory depression in the patient?
- A. Administering naloxone prophylactically
- B. Monitoring oxygen saturation with pulse oximetry
- C. Encouraging deep breathing exercises
- D. Administering bronchodilators as needed
Correct Answer: B
Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.