A nurse received a handover to take care of four patients. After gathering the necessary information, the nurse planned the care.
Considering the priority of nursing care, which of the following cases the nurse would assess FIRST?
Answer : B
Prioritizing Nursing Care:
Using the ABC (Airway, Breathing, Circulation) framework, conditions affecting airway and breathing are top priorities.
Case Analysis:
Abdominal Pain: Important but not life-threatening.
Chest Tightness: Potential sign of a cardiac event or respiratory distress, requiring immediate assessment.
Diabetic Foot: Needs attention but not immediately life-threatening.
Cataract Surgery: Scheduled, no immediate threat.
American Heart Association (AHA) guidelines
Nursing textbooks on prioritization in patient care
A nurse is providing education to a new parent about the psychosocial development of the newborn.
Applying Erikson's psychosocial development theory, the nurse would BEST instruct the parents to:
Answer : C
Applying Erikson's psychosocial development theory, the nurse should instruct the parents to observe and respond to the newborn's signals of needs. According to Erikson, the first stage of psychosocial development is 'Trust vs. Mistrust,' which occurs from birth to approximately 18 months.
Trust vs. Mistrust: In this stage, infants learn to trust their caregivers when their needs for food, comfort, and affection are consistently met. If caregivers are responsive to the infant's needs, the infant develops a sense of trust and security.
Ignoring and Distracting the Newborn: This approach may lead to feelings of mistrust as the infant's needs are not being adequately addressed.
Anticipating and Planning for the Newborn's Demands: While planning is important, it is more crucial to be responsive to the infant's immediate signals.
Providing a Comfortable Environment: This is beneficial but must be combined with responsive caregiving to establish trust.
Erikson, E. H. (1963). Childhood and Society.
American Psychological Association (APA): Erikson's Stages of Psychosocial Development
A client refuses to take an oral dose of Dulcolax (Bisacodyl tablets).
What is the nurse's BEST response?
Answer : A
Handling Medication Refusal:
When a patient refuses medication, the nurse must assess the reason and ensure the patient's safety and adherence to treatment plans.
Best Actions:
Report to the Physician: Ensures the healthcare provider is aware and can make necessary adjustments or provide alternatives.
Crushing Medication and Mixing: Bisacodyl tablets should not be crushed as it can alter the drug's effectiveness and increase side effects.
Informing about Dosing: Not helpful if the patient is already refusing.
Ice Chips: Not relevant to enhancing medication compliance.
American Nurses Association (ANA) on patient medication administration
Pharmacology guidelines on Bisacodyl administration
A nurse is performing a chest physical assessment on a client with asthma.
Which of the following lung sounds the nurse expects to hear?
Answer : C
In a chest physical assessment of a client with asthma, the nurse expects to hear wheezes.
Wheezes: These are high-pitched, musical sounds heard during expiration (and sometimes inspiration) caused by narrowing or obstruction of the airways.
Stridor: This is a high-pitched sound usually heard on inspiration, typically associated with upper airway obstruction, not asthma.
Crackles: These are popping sounds heard during inspiration, often associated with conditions like pneumonia or heart failure, not typical for asthma.
Diminished Lung Sounds: This can occur in severe asthma but is less common compared to wheezes.
American Thoracic Society: Asthma Diagnosis and Monitoring
National Institute of Allergy and Infectious Diseases (NIAID): Asthma Symptoms and Diagnosis
A nurse is caring for a patient with retinal detachment who is posted for retinopexy surgery.
The INITIAL nursing intervention in order to maintain pressure for reattaching the sensory retina:
Answer : B
Retinal Detachment and Retinopexy:
Retinal detachment is a serious condition where the retina peels away from its underlying layer. Retinopexy surgery is performed to reattach the retina.
Initial Nursing Interventions:
Eye patch and dressing: Helps maintain pressure on the retina and prevent movement that could disrupt the reattachment process.
Prone position and avoiding lying on surgical side: These are not specific standard initial interventions.
Aseptic technique: Important but not the primary initial intervention for maintaining retinal attachment pressure.
American Academy of Ophthalmology (AAO) guidelines on Retinal Detachment
Mayo Clinic guidelines on Retinopexy Surgery
A nurse is caring for a patient who is admitted into the surgical ward and was diagnosed with perforated appendix and is shifted to operation room for appendectomy.
The nurse understands that this procedure is classified as:
Answer : B
A perforated appendix is a medical emergency requiring immediate surgical intervention to prevent complications such as peritonitis and sepsis. Therefore, an appendectomy in this context is classified as an emergent procedure. Emergent surgeries are those that need to be performed without delay to preserve the patient's life or health.
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.
At the end of the year, the head nurse decided to motivate the nurses for their teamwork.
Which of the following would be the MOST appropriate action?
Answer : D
Motivating Nurses and Teamwork:
Recognizing and appreciating the efforts of nurses is crucial for maintaining morale and encouraging teamwork.
Best Approach:
Email Appreciation and Memo: These are impersonal and might not effectively motivate the team.
Morning Shift Report Discussion: Useful for daily updates but less formal and might miss some members.
Ward Meeting Acknowledgment: Publicly recognizing individual contributions in a ward meeting is more personal and impactful. It allows team members to feel valued and appreciated in front of their peers, boosting morale and motivation.
Journal of Nursing Management on Team Motivation
American Nurses Association (ANA) on Nurse Recognition and Rewards