A nurse is assessing a patient's pain using a pain rating scale. What action by the nurse demonstrates cultural competence in pain assessment?

Correct Answer: C

Rationale: Choosing option C, asking the patient about their cultural beliefs and preferences related to pain, demonstrates cultural competence in pain assessment. Pain experiences can vary greatly across different cultures, and a patient's cultural background can influence how they perceive and express pain. By inquiring about the patient's cultural beliefs and preferences, the nurse can gain a better understanding of the patient's perspective on pain. This information is crucial for providing individualized and culturally sensitive pain management interventions. It also shows respect for the patient's unique cultural background and helps build a trusting and collaborative relationship between the nurse and the patient.

Correct Answer: A

Rationale: Providing education on techniques to improve latch and milk transfer should be prioritized to support successful breastfeeding in this situation. Newborns who are macrosomic (large for gestational age) may have difficulties latching due to their size and may require additional support to effectively breastfeed. By educating the postpartum client on proper latch techniques and milk transfer, the nurse can help optimize the breastfeeding experience for both the mother and baby. This intervention focuses on addressing the specific concerns related to the infant's size and aims to promote successful breastfeeding despite potential challenges. As such, recommending supplemental formula feedings, encouraging the client to avoid breastfeeding, or immediately referring to a lactation consultant may not directly address the immediate need for support in improving breastfeeding in this situation.

Correct Answer: C

Rationale: Choosing option C, asking the patient about their cultural beliefs and preferences related to pain, demonstrates cultural competence in pain assessment. Pain experiences can vary greatly across different cultures, and a patient's cultural background can influence how they perceive and express pain. By inquiring about the patient's cultural beliefs and preferences, the nurse can gain a better understanding of the patient's perspective on pain. This information is crucial for providing individualized and culturally sensitive pain management interventions. It also shows respect for the patient's unique cultural background and helps build a trusting and collaborative relationship between the nurse and the patient.

Correct Answer: D

Rationale: A patient with chronic kidney disease prescribed a low-protein diet should avoid high-protein foods like grilled salmon, lentil soup, and beef stew. Chicken Caesar salad, on the other hand, typically contains a smaller amount of protein compared to the other options. This choice indicates an understanding of the need to limit protein intake while still enjoying a balanced meal. However, it is important to note that the quantity and portion sizes of high-protein ingredients in the salad should also be moderate to comply with a low-protein diet.

Correct Answer: D

Rationale: Nurse Rey can be liable for committing malpractice. Malpractice refers to professional negligence or failure to provide the standard of care expected in a particular medical situation. In this scenario, Nurse Rey is not qualified or authorized to perform circumcisions, as it falls outside of the scope of practice for a nurse. By participating in performing circumcisions without the necessary qualifications and training, Nurse Rey is potentially putting patients at risk and not providing the appropriate standard of care expected from a healthcare professional. This could be considered as malpractice, for which Nurse Rey may be held liable.

Correct Answer: B

Rationale: In this scenario, the nurse is asking the patient to elaborate on their feelings and thoughts related to the upcoming surgery. By asking, "What do you fear MOST about your surgery tomorrow?" the nurse is seeking clarification to better understand the patient's concerns and enable effective communication. Seeking clarification involves asking open-ended questions that encourage the patient to express themselves more fully, allowing the healthcare provider to address their specific worries or needs more effectively.

Correct Answer: D

Rationale: Transcription errors are typically associated with issues such as illegible handwriting, misinterpretation of directions, and the use of unapproved abbreviations. However, the wrong route of medication administration is not specifically related to transcription errors but rather falls under the category of medication administration errors. Administering medication via the wrong route can lead to serious consequences for the patient and is a separate issue from the act of transcribing doctor's orders.

Correct Answer: A

Rationale: The appropriate sequence of steps in the assessment of a conscious trauma patient is the ABCDE approach, which stands for Airway, Breathing, Circulation, Disability, and Exposure.

Correct Answer: B

Rationale: The responsibility of obtaining informed consent typically falls on the physician or the healthcare provider who is performing the procedure or treatment. Informed consent is a process where the healthcare provider explains the procedure, its risks, benefits, possible alternatives, and potential outcomes to the patient or their legal representative. The patient must have a comprehensive understanding of these aspects before agreeing to the treatment. While nurses, nurse managers, anesthesiologists, midwives, and other healthcare professionals may assist in the consent process by providing information or clarifications, the ultimate responsibility lies with the physician. This is because the physician is usually the one with the expertise and knowledge about the specific procedure or treatment being performed.