During surgery, the nurse notices that the patient's blood pressure is trending higher than the baseline. What action should the nurse take?

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Question 1 of 5

During surgery, the nurse notices that the patient's blood pressure is trending higher than the baseline. What action should the nurse take?

Correct Answer: C

Rationale: The correct answer is C: Notify the anesthesia provider for further assessment. This is the most appropriate action because an anesthesia provider is trained to assess and manage changes in blood pressure during surgery. Administering antihypertensive medication (A) without proper assessment can be dangerous. Documenting the readings (B) is important but not the immediate action. Continuing to monitor closely (D) is necessary but notifying the anesthesia provider for further assessment should be the priority.

Question 2 of 5

A nurse is conducting an admission assessment for a newly admitted patient. What aspect of cultural competence should the nurse prioritize during the assessment?

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Asking the patient about their cultural background and preferences shows respect for their individuality and acknowledges the importance of cultural competence in providing person-centered care. 2. It allows the nurse to gain valuable insights into the patient's beliefs, values, and practices, enabling them to deliver culturally appropriate care. 3. By prioritizing this aspect, the nurse can establish rapport, build trust, and enhance communication with the patient, leading to better outcomes. 4. Choices A, C, and D are incorrect as they either involve assumptions, avoidance, or disregard for the patient's cultural background, which can lead to misunderstandings, discomfort, and ineffective care.

Question 3 of 5

A nurse is conducting a discharge planning assessment for a patient preparing to transition home. What action by the nurse demonstrates continuity of care?

Correct Answer: C

Rationale: The correct answer is C because communicating with the patient's primary care provider and community resources demonstrates continuity of care. This action ensures a seamless transition from the hospital to home by keeping all involved parties informed and involved in the patient's care. Option A (written discharge instructions only) may provide information but lacks coordination with other healthcare providers. Option B (discharging without follow-up care coordination) can lead to gaps in care. Option D (disregarding patient concerns) goes against patient-centered care and can disrupt the continuity of care.

Question 4 of 5

A nurse is preparing to perform a chest tube insertion for a patient with a pneumothorax. What action should the nurse prioritize to ensure proper placement of the chest tube?

Correct Answer: D

Rationale: The correct answer is D because confirming the insertion site and direction using imaging guidance ensures precise placement of the chest tube, minimizing the risk of complications. Imaging guidance allows the nurse to visualize the exact location of the pneumothorax and guide the tube insertion accurately. A: Positioning the patient in a semi-Fowler's position with arms elevated may be beneficial for comfort but does not directly ensure proper chest tube placement. B: Marking the insertion site with a pen may help as a reference point but does not guarantee accurate placement. C: Administering analgesia is important for the patient's comfort but does not impact the placement of the chest tube. In summary, choice D is the most critical step to ensure the chest tube is correctly placed and effectively treats the pneumothorax.

Question 5 of 5

A nurse is preparing to assist with a lumbar epidural steroid injection (LESI) procedure for a patient with chronic back pain. What action should the nurse prioritize to ensure procedural accuracy?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Confirming the patient's identity ensures the right patient is receiving the intended procedure. 2. Verifying the procedure site using two identifiers prevents errors in site selection. 3. This step aligns with the World Health Organization's Surgical Safety Checklist, reducing the risk of wrong-site procedures. 4. Positioning, sedation, and local anesthesia are important but secondary to ensuring the correct patient and site. Summary: - Option B: Positioning is essential but not the top priority for procedural accuracy. - Option C: Sedation aims to minimize discomfort but does not guarantee procedural accuracy. - Option D: Administering local anesthesia is crucial but not as critical as confirming patient identity and procedure site.

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