A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patients immediate postoperative recovery?

Correct Answer: C

Rationale: The correct answer is C: Assessing and addressing the patient's emotional needs. This should be prioritized because the patient has undergone a traumatic experience losing their eye due to a workplace accident. Emotions such as fear, anxiety, and grief are common postoperatively. Addressing these emotional needs is crucial for the patient's overall well-being and recovery. Options A, B, and D are important aspects of care but not the priority in this situation. Teaching about eye prostheses, depth perception, and medication regimen can be addressed once the patient's emotional needs are stabilized.

Correct Answer: B

Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage. A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring. C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads. D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.

Correct Answer: B

Rationale: The correct answer is B because turning off the television is necessary for effective learning and communication between the nurse preceptor and student nurse. Watching TV can be distracting and disrespectful during the learning process. Choices A, C, and D are incorrect because chewing gum, speaking clearly and loudly, and using at least 14-point print are behaviors that do not hinder the learning process and can be acceptable in a professional setting.

Correct Answer: B

Rationale: The correct answer is B: Keep the lesions clean and dry. This intervention helps prevent infection and promotes healing. Cleaning the lesions reduces the risk of secondary infections and discomfort. Keeping the area dry can also help alleviate pain and discomfort associated with moisture. Covering with a topical antibiotic (A) may not address pain directly and could potentially irritate the lesions. Applying a topical NSAID (C) may provide some pain relief but does not address the primary need to keep the lesions clean and dry. Remaining on bed rest (D) is not necessary for managing acute pain related to genital lesions.

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.

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.

Correct Answer: C

Rationale: The correct answer is C because it includes all necessary components for a complete and accurate chart entry. The nurse documents the date and time of the order, the medication prescribed (Morphine, 2 mg, IV every 4 hours), the indication for use (incisional pain), the intended recipient (Dr. Day), the nurse's name (J. Winds), and confirmation of the read-back procedure. This entry ensures clarity, accountability, and proper communication among healthcare team members. Choice A is incorrect because it misses the recipient of the order (Dr. Day) and only includes the nurse's name in the read-back. Choice B is incorrect because it lacks the recipient of the order and the confirmation of the read-back procedure with the primary care provider. Choice D is incorrect because it does not specify the primary care provider who gave the order and misses the read-back confirmation with the provider.

Correct Answer: B

Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection. A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal. C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem. D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.

Correct Answer: B

Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.