A patient is attracted to the nurse and attempts to initiate a social relationship. It is most appropriate for the nurse to take which action?

Correct Answer: C

Rationale: The correct answer is C because it maintains professional boundaries, prioritizing the patient's well-being. By clearly stating that the relationship must remain professional, the nurse sets clear boundaries and avoids any potential ethical issues. Choice A is incorrect as it can lead to boundary violations and compromise patient care. Choice B is incorrect as it does not address the situation directly and may not be necessary if proper boundaries are set. Choice D is incorrect as transferring the patient may not address the underlying issue and is not a standard response to this situation.

Correct Answer: C

Rationale: The correct answer is C: Assess for McBurney sign. The McBurney sign is indicative of appendicitis and involves tenderness at McBurney's point in the right lower quadrant. This assessment is crucial for identifying possible appendicitis in a patient presenting with abdominal pain. Assessing for Cullen sign (A) involves bruising around the umbilicus and is associated with intra-abdominal bleeding, not appendicitis. Grey-Turner sign (B) refers to bruising on the flanks and is also indicative of intra-abdominal bleeding. Chvostek sign (D) is a clinical sign of facial muscle twitching and is associated with hypocalcemia. Therefore, assessing for McBurney sign is the most appropriate choice in this scenario to help diagnose appendicitis.

Correct Answer: A

Rationale: The correct answer is A: Administer filgrastim 5 mcg/kg subcutaneously every day. The rationale for this is that filgrastim is a medication commonly prescribed for patients with non-Hodgkin lymphoma to stimulate the production of white blood cells. Therefore, the team leader should question the dosage, route of administration, and frequency to ensure it aligns with the prescribed treatment plan. Incorrect choices: B: Catheterize to obtain a urinalysis specimen - This is not relevant to the prescribed treatment for non-Hodgkin lymphoma. C: Flush the IV saline lock every shift - Important for maintaining IV access but not directly related to the prescribed medication. D: Monitor vital signs every 4 hours - Monitoring vital signs is important but not the primary concern when reviewing a prescribed medication for non-Hodgkin lymphoma.

Correct Answer: A

Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety. Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding. Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding. Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.

Correct Answer: C

Rationale: The correct answer is C because after BCG treatment, the fluid in the urinary drainage bag is considered hazardous due to the live bacteria used in the treatment. Therefore, instructing the UAP to discard the fluid in the toilet and disinfect it with bleach is crucial to prevent the spread of infection. This step helps to ensure proper disposal and minimize the risk of exposure to others. Choice A is incorrect because special handling is indeed required due to the nature of the contents. Choice B is incorrect as wearing a lead apron is not necessary for handling the fluid in the urinary drainage bag. Choice D is also incorrect as sterile gloves are not specifically required for this task; instead, proper disinfection of the toilet is essential.