Nokea
When the nurse takes a surgical consent form to an Asian woman for a signature after the surgeon has provided the information about the recommended surgery, the patient refuses to sign the consent form. What is the best response by the nurse?
- A. Didn’t you understand what the doctor told you about the surgery?
- B. Are there others with whom you want to talk before making this decision?
- C. Why won’t you sign this form? Do you want to do what the doctor recommended?
- D. I’ll have to call the surgeon and have your surgery cancelled until you can make a decision.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A terminally ill man tells the nurse, “I have never believed there is a God or an afterlife, but now it is too terrible to imagine that I will not exist. Why was I here in the first place?” What does this comment help the nurse recognize about the patient’s needs?
- A. He is experiencing spiritual distress.
- B. This man most likely will not have a peaceful death.
- C. He needs to be reassured that his feelings are normal.
- D. This patient should be referred to a clergyman for a discussion of his beliefs.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically adjust the oxygen flow rate.
- C. Remove the tubing from the client's nose.
- D. Turn the client every 2 hours or as needed.
Correct Answer: A
Rationale: The correct answer is A - Apply water-soluble ointment to nares and lips. This is an appropriate comfort measure that can be safely delegated to UAP as it helps prevent dryness and irritation caused by the oxygen flow. UAP can apply ointment without adjusting the oxygen flow rate (B), which should be done by licensed staff. Removing the tubing (C) can disrupt oxygen delivery. Turning the client (D) is important for preventing pressure ulcers but is not directly related to oxygen therapy comfort.
A patient comes to the clinic with a complaint of a dull pain in the anterior and posterior neck. On examination, the nurse notes that the patient has full range of motion (ROM) of the neck and no throat redness or enlarged head or neck lymph nodes. What will be the nurse’s next appropriate assessment indicated by these findings?
- A. Palpation of the liver
- B. Auscultation of bowel sounds
- C. Inspection of the patient’s ears
- D. Palpation for the presence of left flank pain
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to:
- A. Check for subcutaneous emphysema in the upper torso.
- B. Reposition the client to a position of comfort.
- C. Call the health care provider as soon as possible.
- D. Check for any increase in the amount of thoracic drainage.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?
- A. Document findings.
- B. Administer O2 therapy.
- C. Position client in high-Fowler's position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct answer is A: Document findings. This is important because the harsh hollow sound over the trachea and larynx could indicate a potential emergency or serious condition like an airway obstruction or laryngeal edema. Documenting findings helps in providing clear communication to other healthcare professionals and ensures proper follow-up care. Administering O2 therapy (B) or albuterol (D) without a clear understanding of the underlying issue could be harmful. Positioning the client in high-Fowler's position (C) may not directly address the potential emergency at hand.