A nurse is teaching a group of nursing students about the importance of professional boundaries in nursing practice. What statement by a student indicates understanding of this concept?

Correct Answer: B

Rationale: Option B, "Maintaining professional boundaries helps protect both patients and nurses," indicates an understanding of the importance of professional boundaries in nursing practice. Professional boundaries define the limits of the nurse-patient relationship and help ensure that interactions are safe, therapeutic, and based on the patient's best interest. By maintaining these boundaries, nurses can uphold ethical standards, prevent harm, and maintain trust with patients. It also helps prevent issues such as transference, countertransference, and breaches of confidentiality. Overall, understanding and respecting professional boundaries are essential for promoting the well-being of both patients and healthcare providers.

Correct Answer: C

Rationale: When the nurse interacts with patients face-to-face to gather information during the assessment phase of the nursing process, the level of communication is considered interpersonal. Interpersonal communication involves two or more individuals who are connected in a meaningful way. In this scenario, the nurse and the patient are engaging in a personal exchange of information, thoughts, and feelings. This type of communication is essential in building rapport, understanding the patient's needs, and providing effective care. It focuses on creating a supportive and therapeutic relationship between the nurse and the patient, which is crucial for delivering high-quality nursing care.

Correct Answer: B

Rationale: The correct answer is to avoid sharing items used by the infected person in order to prevent the spread of Scabies infestation to other residents in the community. Scabies is a highly contagious skin infestation caused by the Sarcoptes scabiei mite, and it can easily spread through direct skin-to-skin contact or by sharing personal items such as clothing, towels, and bedding. By advising the family to avoid sharing items used by the infected person, Nurse Emma is helping to prevent the transmission of the mites to others in the community. Boiling utensils, taking excessive baths, or wearing masks and shields are not necessary preventive measures for scabies infestation.

Correct Answer: D

Rationale: While all of the nursing measures listed are important considerations when managing a patient receiving oxytocin drip, the nurse would least consider informing the patient about potential complications. The reason for this is that it is the responsibility of the healthcare provider (such as the physician or advanced practice nurse) to inform the patient about potential complications of a medication or treatment. Nurses are instrumental in providing education and support to patients, but in the case of informing patients about potential complications, this task typically falls under the purview of the prescribing provider. The primary focus of the nurse in this situation would be to assess, administer, monitor, and educate the patient as appropriate, ensuring safe and effective care delivery.

Correct Answer: A

Rationale: Long-term corticosteroid use in patients with rheumatoid arthritis can lead to osteoporosis, which is a common complication. Osteoporosis causes weakening of the bones, increasing the risk of fractures, particularly in weight-bearing bones such as the hip, spine, and wrist. Osteoporotic fractures are a significant concern in patients on long-term corticosteroid therapy, highlighting the importance of monitoring bone health and considering preventive measures such as calcium, Vitamin D supplementation, and regular bone density testing. While osteonecrosis of the femoral head and avascular necrosis of the talus can also occur as complications of corticosteroid use, osteoporotic fractures are more commonly associated with this type of therapy in patients with rheumatoid arthritis. Septic arthritis, on the other hand, is not directly related to corticosteroid use but can occur due to other factors such as joint infections.

Correct Answer: D

Rationale: Following an amniotomy procedure during labor, Nurse Hope's priority should be to assess the fetal heart rate (FHR) pattern. This assessment is crucial to ensure the well-being and safety of the fetus. Changes in the FHR can provide valuable information about fetal distress or complications, allowing for timely interventions if needed. Monitoring the FHR pattern is a standard practice during labor and delivery to track the fetus's response to the changes in uterine activity. Therefore, assessing the FHR pattern should be the first priority after a labor progress and amniotomy.

Correct Answer: C

Rationale: Insulin glargine (Lantus) is a long-acting insulin that is typically administered once daily at the same time each day to help maintain a steady level of insulin in the body. It is important to rotate injection sites within the same body region (such as the abdomen, thigh, or upper arm) to prevent lipodystrophy (lumpiness or dents in the skin) and to ensure consistent absorption of the insulin. Proper rotation of injection sites helps to prevent tissue damage and ensures optimal insulin absorption, improving the effectiveness of insulin therapy. It is not necessary to inject insulin glargine before meals, vigorously shake the vial, or administer it with a rapid-acting insulin.

Correct Answer: C

Rationale: RA 9173, also known as the Philippine Nursing Act of 2002, is the law that declares the State policy to promote and upgrade the practice of the nursing profession in the Philippines. This law provides for the regulation and maintenance of high standards of nursing education and practice in the country. It aims to ensure the welfare and professional growth of Filipino nurses and to safeguard the health of the public by maintaining competency and professionalism in the nursing profession. Therefore, RA 9173 is the correct choice that reflects the State's policy to promote and upgrade the practice of the nursing profession in the Philippines.

Correct Answer: C

Rationale: When conducting a nursing history on the Health Perception, Health Management pattern of functioning pre-operatively, an appropriate question to ask would be "Are you aware of risk factors for your disease?" This question helps assess the individual's level of awareness and understanding of their health condition and the factors that may impact it. Understanding the patient's knowledge of their risk factors can help guide interventions and education before surgery to optimize their health outcomes. Asking about perceived wound healing, shortness of breath, or weight changes may not be directly related to the patient's awareness of their disease risk factors in the pre-operative setting.