Nokea
Which assessment finding is the most critical and needs to be addressed first?
- A. Mr. U has tracheal deviation after a pulmonary resection.
- B. Mr. B, with bladder cancer, has decreased urinary output.
- C. Mr. N, with non-Hodgkin lymphoma, is having dysrhythmias.
- D. Ms. C has severe abdominal pain after a bowel resection.
Correct Answer: A
Rationale: The correct answer is A because tracheal deviation after a pulmonary resection indicates a life-threatening condition like tension pneumothorax. This condition requires immediate intervention to prevent respiratory distress and potential cardiovascular collapse. Tracheal deviation is a red flag sign that signals a medical emergency. Options B, C, and D are important but not as urgent as tracheal deviation. Decreased urinary output in a bladder cancer patient could indicate renal dysfunction, dysrhythmias in a patient with non-Hodgkin lymphoma may need further evaluation, and severe abdominal pain post-bowel resection could signal complications but are not as immediately life-threatening as tracheal deviation.
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A patient is irritable and complains to the nurse about difficulty sleeping last night. Which response by the nurse is most appropriate?
- A. "I know you will sleep better tonight.=
- B. "Tell me more about what happened last night.=
- C. "Did you drink too much caffeine yesterday?=
- D. "No one sleeps well in the hospital.=
Correct Answer: B
Rationale: The correct response is B. Asking the patient to elaborate on what happened last night allows the nurse to gather more information about the situation, which is crucial for assessing the patient's sleep difficulties accurately. It shows active listening and empathy, building rapport and trust with the patient. Options A, C, and D are incorrect because they do not address the patient's concerns effectively or gather relevant information to provide appropriate care. Option A makes an assumption without understanding the root cause of the sleep issue. Option C assumes the cause of sleep difficulty without exploring further. Option D dismisses the patient's concerns without providing support or understanding.
A nurse preceptor is assigned to help several graduate nurses assess their ability to convey warmth to patients. Which activity, if selected by the nurse preceptor, is best?
- A. Set up sessions for the graduate nurses to practice various nonverbal gestures.
- B. Ask the graduate nurses to record the behaviors of experienced nurses on the unit.
- C. Provide the graduate nurses with a list of nonverbal behaviors that convey warmth.
- D. Have the graduate nurses evaluate each other during simulated patient interviews.
Correct Answer: A
Rationale: The correct answer is A because setting up sessions for the graduate nurses to practice various nonverbal gestures allows for active skill development. By practicing these gestures, they can receive immediate feedback from the preceptor and improve their ability to convey warmth effectively.
Choice B is incorrect because simply observing behaviors of experienced nurses may not actively engage the graduate nurses in practicing and developing their own skills.
Choice C is incorrect because providing a list of nonverbal behaviors may not be as effective as hands-on practice in improving the graduate nurses' ability to convey warmth.
Choice D is incorrect because having the graduate nurses evaluate each other during simulated interviews may not provide structured guidance and feedback from the preceptor to help them improve their nonverbal communication skills effectively.
In order to safeguard patient information when using a computer, the nurse should:
- A. only use the computer located in the nurse's station.
- B. wait until the end of the shift and document all information at one time.
- C. use personal code words and abbreviations to disguise information.
- D. change the computer password frequently. Computerized patient information requires extra vigilance by the nurse to safeguard confidentiality. Changing personal passwords frequently helps safeguard information. When using the computer at a health care facility, the nurse must remember not to leave a computer screen open when he or she is finished. The nurse should always log out so that someone else cannot access information using his or her password and must not share his or her password with others. Computers in the nurse's station are not as convenient as those at the bedside or in the hall. Personal codes and abbreviations are not useful.
Correct Answer: D
Rationale: The correct answer is D: change the computer password frequently. This is essential to safeguard patient information on a computer. Changing passwords regularly enhances security by reducing the risk of unauthorized access. By doing so, the nurse ensures that even if someone gains access to their password, it will soon be outdated. This practice aligns with best practices for maintaining confidentiality and data security.
Now, let's analyze the other choices:
A: Using only the computer at the nurse's station limits flexibility and convenience for accessing patient information.
B: Waiting until the end of the shift to document information increases the risk of errors and delays in updating patient records.
C: Using personal code words and abbreviations may lead to misinterpretation of information and compromise patient confidentiality.
In summary, changing the computer password frequently is the most effective measure to safeguard patient information on a computer, while the other options do not provide the same level of security and confidentiality.
Which characteristic would the nurse use to define culture? (Select all that apply)
- A. Learned and shared lifeways of a particular group.
- B. Social identity influenced by language and religion.
- C. Belief in superiority of one's own ethnic group.
- D. Values influence both thinking and actions.
Correct Answer: A
Rationale: The correct answer is A because culture is defined as the learned and shared lifeways of a particular group. This includes traditions, customs, beliefs, and practices that are passed down from generation to generation within a community. This definition aligns with the concept of culture being a set of learned behaviors and beliefs that are commonly practiced and shared among individuals in a society.
Choice B is incorrect because while social identity can be influenced by language and religion, it does not fully encompass the complexity of culture. Choice C is incorrect as it refers to ethnocentrism, which is the belief in the superiority of one's own ethnic group and is not a defining characteristic of culture. Choice D is incorrect because while values do influence thinking and actions within a culture, it does not capture the entirety of what culture entails, such as traditions, customs, and shared beliefs.
Ms. C (bowel resection and colostomy) is receiving epoetin alfa. Which laboratory test will the nurse check to see if the medication should be discontinued?
- A. Hemoglobin
- B. White cell count
- C. Potassium level
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is A: Hemoglobin. Epoetin alfa is a medication that stimulates red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of the medication. If hemoglobin levels rise too high, it can lead to complications like blood clots. Checking hemoglobin levels helps determine if the dose of epoetin alfa should be adjusted or discontinued.
Summary:
B: White cell count - Monitoring white cell count is not directly related to epoetin alfa therapy.
C: Potassium level - Monitoring potassium level is important for other medications like diuretics or ACE inhibitors, not specifically for epoetin alfa.
D: Blood glucose level - Monitoring blood glucose level is important for diabetic patients but not directly related to epoetin alfa therapy.