Nokea
Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?
- A. Opening the patient's window to the outside environment
- B. Turning on the patient's room ventilator
- C. Opening the door of the patient's room leading into the hospital corridor
- D. Failing to wear gloves when administering a bed bath
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct Answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
During a Romberg test, the patient is asked to assume which position?
- A. Sitting
- B. Standing
- C. Genupectoral
- D. Trendelenburg
Correct Answer: B
Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.
In Maslow's hierarchy of physiological needs, the human need of greatest priority is:
- A. Love
- B. Elimination
- C. Nutrition
- D. Oxygen
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following interventions promotes patient safety?
- A. Assess the patient's ability to ambulate and transfer from a bed to a chair
- B. Demonstrate the signal system to the patient
- C. Check to see that the patient is wearing their identification band
- D. All of the above
Correct Answer: D
Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient's ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.
When discussing hair loss with Mrs. Lim, who begins to cry, the best response would be:
- A. Don't worry. It's only temporary
- B. Why are you crying? I didn't get to the bad news yet
- C. Your hair is really pretty
- D. I know this will be difficult for you, but your hair will grow back after the completion of chemotherapy
Correct Answer: D
Rationale: When a patient is emotionally affected, it is essential to acknowledge their feelings while providing reassurance and information. Option D demonstrates empathy by acknowledging the difficulty Mrs. Lim is facing and offers hope by reassuring her that her hair will grow back after chemotherapy, which can provide comfort and support during a challenging time.