Nokea
Which assessment finding for Mr. L (tracheostomy and partial laryngectomy) would be of greatest concern?
- A. Pulsation of the tracheostomy tube in synchrony with the heartbeat
- B. Increased secretions in and around the tracheostomy
- C. Increased coughing, with difficulty in expectorating secretions
- D. Presence of food particles in tracheal secretions
Correct Answer: A
Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety.
Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding.
Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding.
Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.
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Which statement, if made by the nurse, could positively affect the course of the patient's situation by suggestibility?
- A. "Breastfeeding will provide time to bond with your baby.=
- B. "Breastfeeding will take longer than giving your baby a bottle.=
- C. "You will need to be careful about taking medications while breastfeeding.=
- D. "Breastfeeding mothers can develop infections that are serious.=
Correct Answer: A
Rationale: The correct answer is A because it emphasizes the positive aspect of breastfeeding, which can influence the patient's perception and behavior positively. By highlighting the bonding experience, the nurse can encourage the patient to view breastfeeding as a rewarding and meaningful activity, potentially increasing the likelihood of successful breastfeeding. Option B focuses on the time aspect and may discourage the patient. Option C introduces a potential negative aspect, which could create fear or uncertainty. Option D mentions a risk of infection, which could lead to anxiety or hesitation. In summary, choice A promotes a positive outlook and emotional connection, making it the most effective in positively affecting the patient's situation.
The nurse cares for an adult client who is diagnosed with active tuberculosis. Which action, if performed by the nurse during introductions, shows respect for the client? (Select all that apply)
- A. Maintain eye contact by looking at the client.
- B. Avoid touch to reduce transmission of the disease.
- C. Stay at least 4 to 6 feet away from the client.
- D. Briefly converse about the weather to break the ice.
Correct Answer: A
Rationale: The correct answer is A. Maintaining eye contact by looking at the client during introductions shows respect by acknowledging the client as an individual and demonstrating active listening. This helps establish trust and rapport.
Incorrect choices:
B: Avoiding touch may be necessary for infection control, but it does not necessarily show respect for the client.
C: Staying 4 to 6 feet away may be necessary for infection control, but it does not demonstrate respect or engagement with the client.
D: Briefly conversing about the weather is a social nicety but may not convey the same level of respect and attentiveness as making eye contact.
The team leader is reviewing what the HCP has just prescribed for Mr. N (non-Hodgkin lymphoma). What will the team leader question?
- A. Administer filgrastim 5 mcg/kg subcutaneously every day
- B. Catheterize to obtain a urinalysis specimen.
- C. Flush the IV saline lock every shift.
- D. Monitor vital signs every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer filgrastim 5 mcg/kg subcutaneously every day. The rationale for this is that filgrastim is a medication commonly prescribed for patients with non-Hodgkin lymphoma to stimulate the production of white blood cells. Therefore, the team leader should question the dosage, route of administration, and frequency to ensure it aligns with the prescribed treatment plan.
Incorrect choices:
B: Catheterize to obtain a urinalysis specimen - This is not relevant to the prescribed treatment for non-Hodgkin lymphoma.
C: Flush the IV saline lock every shift - Important for maintaining IV access but not directly related to the prescribed medication.
D: Monitor vital signs every 4 hours - Monitoring vital signs is important but not the primary concern when reviewing a prescribed medication for non-Hodgkin lymphoma.
According to Kimble and Bamford-Wade, what distinguishes the behavior of one caring and competent nurse from another nurse who is simply competent but not engaged with the patient?
- A. Immediacy, the availability of the nurse
- B. Warmth, the hallmark of compassion
- C. Attention, the focus of the nurse
- D. Communication, the instructional side of the nurse
Correct Answer: B
Rationale: The correct answer is B: Warmth, the hallmark of compassion. This is because warmth, or the ability to convey care and empathy, is what distinguishes a caring and competent nurse from one who is simply competent but lacks emotional engagement. Kimble and Bamford-Wade emphasize the importance of compassion and connection in nursing care, as it enhances the patient experience and contributes to better outcomes.
A: Immediacy, the availability of the nurse - While being available and responsive is important, it does not necessarily capture the essence of emotional connection and compassion in nursing care.
C: Attention, the focus of the nurse - While attention and focus are crucial in providing quality care, they do not fully encapsulate the emotional aspect of caring that sets one nurse apart from another.
D: Communication, the instructional side of the nurse - Effective communication is essential in nursing, but it primarily addresses the transfer of information rather than the emotional connection and compassion that define a caring nurse.
The nurse is caring for a patient who states, "I tossed and turned last night." The nurse responds to the patient, "You feel like you were awake all night?" This is an example of:
- A. open-ended question.
- B. restatement.
- C. reflection.
- D. offering self. Restatement is a
Correct Answer: B
Rationale: The correct answer is B: restatement. Restatement involves repeating the patient's words to confirm understanding. In this scenario, the nurse echoed the patient's statement to show empathy and acknowledge the patient's feelings. This technique helps build rapport and fosters therapeutic communication.
Explanation of why other choices are incorrect:
A: Open-ended question: This involves encouraging the patient to elaborate on their feelings or experiences, not just repeating what the patient said.
C: Reflection: This involves restating the patient's feelings to show understanding, not simply repeating their words.
D: Offering self: This involves offering oneself to the patient for support, which was not demonstrated in the scenario.