During surgery, the nurse notices an abnormal heart rhythm on the patient's cardiac monitor. What is the nurse's priority action?

Correct Answer: B

Rationale: The nurse's priority action when noticing an abnormal heart rhythm on the patient's cardiac monitor during surgery is to assess the patient's vital signs and symptoms. This is important because the nurse needs to gather more information about the patient's condition to determine the significance of the abnormal rhythm and the potential impact on the patient's health. By assessing the vital signs and symptoms, the nurse can obtain a more complete picture of the situation and make informed decisions about the next steps in caring for the patient. Once the assessment is done, appropriate actions such as administering medication or notifying the anesthesiologist can be taken based on the findings.

Correct Answer: B

Rationale: Offering reassurance and encouragement to the patient demonstrates therapeutic communication by the nurse. In this situation, the nurse shows empathy and understanding towards the patient's concerns about the upcoming surgical procedure, which can help alleviate anxiety and build trust. Providing reassurance and encouragement can help the patient feel supported and understood, creating a positive and therapeutic interaction between the nurse and the patient. This approach fosters open communication and helps establish a therapeutic nurse-patient relationship, which is essential for effective patient care.

Correct Answer: C

Rationale: The correct action for the nurse to take when observing signs of distress and discomfort in a patient during assessment is to offer emotional support and actively listen to the patient's concerns. Ignoring the patient's distress may lead to worsening of the patient's condition and can be detrimental to the patient's well-being. Documenting the findings and informing the healthcare provider later is important but should not be the immediate response when a patient is in distress. Administering pain medication without further assessment is also not appropriate as the nurse needs to understand the underlying cause of the distress before providing appropriate interventions. Offering emotional support and actively listening to the patient's concerns can help the nurse understand the patient's needs, provide comfort, and potentially address the root cause of the distress.

Correct Answer: C

Rationale: The nurse should obtain interpreter services or language assistance as needed to ensure effective communication with a patient who has limited English proficiency. Using an interpreter will facilitate clear and accurate communication between the nurse and the patient, enabling the patient to fully understand their care, treatment, and any instructions provided. Speaking loudly or slowly, using medical jargon, or ignoring the language barriers are not effective strategies for communicating with a patient who has limited English proficiency. Utilizing interpreter services demonstrates respect for the patient's language and cultural needs, which is essential for providing high-quality care.

Correct Answer: C

Rationale: The nurse should prioritize removing the old dressing and applying a new dressing using sterile technique to minimize the risk of infection during a central venous catheter (CVC) dressing change. This is because the most critical step in preventing infection is maintaining a clean and sterile environment around the CVC insertion site. By using sterile technique, the nurse can reduce the introduction of microorganisms that could potentially lead to infection. Wearing sterile gloves and cleaning the insertion site with an alcohol-based antiseptic solution are important steps as well, but the key priority lies in applying the new dressing using sterile technique to prevent contamination and reduce the risk of infection.