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Which piece of data will the nurse use for “B” when using SBAR?
- A. Having chest pain
- B. Pulse rate of 108
- C. History of angina
- D. Oxygen is needed
Correct Answer: C
Rationale: The nurse will use the history of angina for "B" when using SBAR because it provides relevant background information about the patient's cardiac condition. This helps the nurse understand the context of the current situation and make appropriate decisions. Pulse rate of 108 (choice B) is a specific vital sign and not an appropriate choice for "B" in SBAR. Having chest pain (choice A) is important but does not provide the necessary background information like the history of angina does. Oxygen being needed (choice D) is a current intervention and not relevant for "B" in SBAR, which focuses on providing background information.
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During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
- A. Ask the social worker to investigate alternative housing arrangements.
- B. Ask the social worker to investigate community support agencies.
- C. Encourage the patient to explore surgical corrections for the vision problem.
- D. Arrange for referral to a rehabilitation facility for vision training.
Correct Answer: D
Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently.
A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management.
B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management.
C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.
A patient has presented with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient?
- A. Promoting adequate perfusion in affected regions
- B. Promoting safe use of topical antihistamines
- C. Identifying the offending agent, if possible
- D. Teaching the patient to safely use an EpiPen
Correct Answer: C
Rationale: The correct answer is C: Identifying the offending agent, if possible. This is prioritized in contact dermatitis to prevent further exposure and recurrence. By identifying the specific irritant or allergen, the nurse can guide the patient in avoiding it, leading to effective management. Choices A, B, and D are incorrect because while promoting adequate perfusion, safe use of topical antihistamines, and teaching the use of an EpiPen may be relevant in certain situations, they do not directly address the root cause of contact dermatitis, which is exposure to the offending agent.
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
- A. Serum albumin level
- B. Weight history
- C. White blood cell count
- D. Body mass index E) Blood urea nitrogen (BUN) level
Correct Answer: A
Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.
The nurse notes that a patient has a history of fibroids and is aware that this term refers to a benign tumor of the uterus. What is a more appropriate term for a fibroid?
- A. Bartholins cyst
- B. Dermoid cyst
- C. Hydatidiform mole
- D. Leiomyoma
Correct Answer: D
Rationale: The correct answer is D: Leiomyoma. A leiomyoma is the medical term for a fibroid, which is a benign tumor of the uterus composed of smooth muscle tissue. This term is more appropriate as it specifically refers to fibroids.
A: Bartholins cyst is a fluid-filled swelling in the Bartholin's gland, not related to fibroids.
B: Dermoid cyst is a type of ovarian cyst containing tissues like hair, teeth, and skin, not related to fibroids.
C: Hydatidiform mole is an abnormal growth of tissue in the uterus that forms during pregnancy, not related to fibroids.
The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is thepriority?
- A. Observe the color of gastric contents.
- B. Verify tube placement before feeding.
- C. Add blue food coloring to the enteral formula.
- D. Run the formula over 12 hours to decrease overload.
Correct Answer: B
Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.