Nurse Ime, is a member of the Quality Assurance team of the hospital and has been always rated as very assertive. Which of the following is NOT a characteristic of an assertive person?

Correct Answer: B

Rationale: Being assertive means expressing one's thoughts, beliefs, and feelings in a confident and respectful manner while also considering the perspective of others. It does not involve pushing control on others. Assertive individuals do not impose their beliefs on others but express themselves clearly and confidently, respecting the opinions of others. So, standing up for what one believes in can be assertive, but pushing control on others is not a characteristic of assertiveness.

Correct Answer: C

Rationale: The nurse should reposition the patient to alleviate pressure on vulnerable areas. Pressure injuries can develop when there is prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage. Repositioning the patient helps to relieve the pressure and prevent the development of pressure injuries. Applying a pressure-relieving device may also be helpful, but the immediate action should be to reposition the patient to address the issue. Documenting the observation is important for documentation purposes, but the priority is to take action to prevent harm to the patient. Continuing with the positioning as planned without addressing the inadequate skin protection could lead to the development of pressure injuries, which should be avoided.

Correct Answer: A

Rationale: The nurse should prioritize using sterile technique during the tracheostomy tube change to ensure patient safety. Tracheostomy procedures involve a direct entry into the airway, making it crucial to prevent infection and reduce the risk of complications. Sterile technique, including proper hand hygiene, wearing sterile gloves, and using sterile equipment, helps minimize the introduction of pathogens into the patient's airway, reducing the risk of infection. By maintaining a sterile field, the nurse can protect the patient from potential harm and promote a successful outcome of the tracheostomy tube change.

Correct Answer: B

Rationale: When a patient is unable to talk, the nurse can best communicate with the patient by using picture cards. Picture cards can help the patient convey their needs, feelings, or responses by pointing to the corresponding pictures. This method allows for effective communication and understanding between the patient and the nurse, even when verbal communication is not possible. It promotes patient autonomy and ensures that their needs are accurately communicated and addressed. Additionally, picture cards can be a useful tool in reducing frustration and anxiety for patients who are unable to communicate verbally.

Correct Answer: C

Rationale: Fowler's position is the correct position to help a patient experiencing breathing difficulty. In Fowler's position, the patient is sitting up at a 45- to 60-degree angle with the legs either straight or bent. This position allows for maximum chest expansion, helping to improve ventilation and oxygenation. It is commonly used to assist patients with respiratory distress, including difficulties with breathing. Placing the patient in Fowler's position can alleviate the feeling of breathlessness and facilitate easier breathing by promoting better lung expansion.

Correct Answer: D

Rationale: Incompetent cervix, also known as cervical insufficiency, is the most likely cause of the symptoms described. Incompetent cervix is a condition where the cervix begins to dilate and efface prematurely, typically in the second trimester, without contractions or labor. This can lead to painless cervical dilation and bulging of the amniotic sac into the vagina, which can cause vaginal bleeding and crampy abdominal pain. It is a leading cause of second-trimester pregnancy loss. Treatment may involve a cervical cerclage, a surgical procedure where the cervix is stitched closed to provide additional support.

Correct Answer: A

Rationale: Clients who are taught skills such as measuring blood glucose, taking blood pressure, changing dressings, and bathing infants are learning skills that involve physical movement and coordination. These activities require the integration of mental and physical skills, and they fall under the psychomotor domain of learning. In this domain, individuals develop physical skills and coordination through practice and repetition. The psychomotor domain is one of the three domains of learning, along with the cognitive domain (which involves knowledge and intellectual skills) and the affective domain (which involves emotions, values, and attitudes).

Correct Answer: A

Rationale: In delegation, facilitating the professional growth and development of a staff is necessary because it allows team members to gain new skills and experience, leading to overall improved productivity and job satisfaction. This empowers staff and helps them feel more engaged in their work, ultimately benefiting the entire unit. Effective delegation should aim to support individuals in their roles, encourage learning, and build competence, rather than modifying standards of care or only delegating tasks without considering individual growth. Starting delegation from top management to staff-nurse level may not always be practical or efficient, as delegation should be based on competencies and responsibilities. Accountability is indeed a crucial aspect of delegation, as individuals should be held responsible for the tasks they are delegated. However, without providing opportunities for professional growth and development, delegation may not be as effective in achieving organizational goals.

Correct Answer: B

Rationale: The ethical principle of autonomy emphasizes respecting the patient's right to make their own decisions regarding their treatment. In this scenario, the patient has the right to refuse treatment, and the nurse should respect that decision while also providing information and guidance to help the patient make informed choices. By upholding the principle of autonomy, the nurse can support the patient's decision-making process and work collaboratively with them to address any concerns or barriers to compliance with the treatment regimen. This approach honors the patient's right to self-determination and promotes a trusting relationship between the nurse and the patient.