Nokea
Which nursing intervention is an independent function of the professional nurse?
- A. Administering oral analgesics
- B. Requesting diagnostic studies
- C. Teaching the patient perineal care
- D. Providing wound care to a surgical incision
Correct Answer: A
Rationale: Administering oral analgesics is an independent function of the professional nurse. Independent nursing interventions are those that a nurse is licensed to initiate based on their knowledge and skills without needing an order from a healthcare provider. Nurses are educated and trained in medication administration, including oral analgesics, and can independently assess the need for and safely administer them within their scope of practice. While requesting diagnostic studies, teaching perineal care, and providing wound care are essential nursing interventions, they typically require some form of healthcare provider's order or supervision, making them more interdependent activities.
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The RN is delegating tasks to the unlicensed assistive personnel (UAP). Which tasks can the nurse delegate? (Select all that apply.)
- A. Teaching the patient about breast care
- B. Assessment of a patient’s lochia and perineal area
- C. Assisting a patient to the bathroom for the first time after birth
- D. Vital signs on a postpartum patient who delivered the night before
Correct Answer: C
Rationale: A. Teaching the patient about breast care typically requires specialized knowledge and is best performed by the nurse.
A patient who is 6 months pregnant has sought medical attention, saying she fell down the stairs. Which scenario would cause an emergency department nurse to suspect that the woman has been battered?
- A. She avoids making eye contact and is hesitant to answer questions.
- B. The woman and her partner are having an argument that is loud and hostile.
- C. The woman has injuries on various parts of her body that are in different stages of healing.
- D. Examination reveals a fractured arm and fresh bruises. Her husband asks her about her pain.
Correct Answer: C
Rationale: In this scenario, the emergency department nurse would be most likely to suspect that the woman has been battered based on the presence of injuries on various parts of her body that are in different stages of healing. This pattern of injuries, known as the "battered woman syndrome," is a red flag for domestic violence. The varying stages of healing indicate that the injuries are not from a single accidental fall down the stairs but rather from repeated incidents of physical abuse. Additionally, the fact that the injuries are in different locations on the body further suggests that they are not the result of a single traumatic event. This situation warrants further investigation and intervention to ensure the safety and well-being of the pregnant woman and her unborn child.
While teaching an Asian patient regarding prenatal care, the nurse notes that the patient refuses to make eye contact. Which is the most likely cause for this behavior?
- A. A submissive attitude
- B. Lack of understanding
- C. Embarrassment about the subject
- D. Cultural beliefs about eye contact
Correct Answer: D
Rationale: In many Asian cultures, avoiding eye contact can be a sign of respect, modesty, or a way to show deference to authority figures. Making direct eye contact during a conversation, especially with someone in a position of authority like a healthcare provider, can be seen as disrespectful or confrontational. Understanding and respecting these cultural beliefs is crucial when providing care to patients from diverse backgrounds. It is important for healthcare providers to be aware of these cultural differences and adjust their communication styles accordingly to ensure effective and culturally sensitive care.
The nurse is caring for a 33-year-old female patient who has just undergone laparoscopic removal of endometrial lesions. Which statement by the patient illustrates her understanding of the disease process and prognosis?
- A. I realize that this is not a cure for the issue, but I want to have more children within the next year.
- B. I'm happy to know that the surgeon has been able to cure me of this disease without a hysterectomy.
- C. I realize that my type 2 diabetes will be cured now that I have those lesions removed
- D. I understand that I will not have to have a colostomy now that the growths were removed from my bowels.
Correct Answer: A
Rationale: Choice A is the correct answer because the patient acknowledges that the laparoscopic removal of endometrial lesions is not a cure for her issue. She demonstrates understanding by mentioning her desire to have more children within the next year, indicating that she recognizes the need for continued monitoring and management of her condition. Choices B, C, D, and E are incorrect because they do not accurately reflect the disease process and prognosis associated with endometrial lesions.
A nurse is caring for a patient with increased urination and pain with urination. What finding would the nurse expect if the patient has a UTI?
- A. white blood cells in urine
- B. ketones in urine
- C. blood in urine
- D. protein in urine
Correct Answer: A
Rationale: When a patient has a urinary tract infection (UTI) they may have increased white blood cells (leukocytes) in their urine. White blood cells are a sign of inflammation and infection in the urinary tract. It is a common finding in patients with UTIs. Symptoms such as increased urination and pain with urination are classic signs of a UTI. Therefore, the nurse would expect to see white blood cells in the urine of a patient with a UTI.