Nurse Selma conducts her INITIAL assessment on Catherine. patient keeps on crying and constantly pulls her right ear. What is her MOST APPROPRIATE action?

Correct Answer: D

Rationale: When a patient is crying and continuously pulling at a specific body part, such as Catherine pulling her right ear, it indicates discomfort or pain in that area. Nurse Selma's most appropriate action would be to further assess the description and frequency of the pain. This will help her identify the possible cause of the pain, whether it is due to an ear infection, injury, or any other underlying issue. Understanding the nature and intensity of the pain will guide Nurse Selma in providing appropriate care and intervention for Catherine. It is crucial to address the patient's pain promptly to ensure their comfort and well-being. Referring to the attending physician may be necessary after this initial assessment but assessing the pain should be the immediate priority.

Correct Answer: B

Rationale: A living will is a legal document that allows an individual to express their wishes regarding medical treatment in the event they become unable to make decisions. It specifically outlines the medical treatments a person chooses to refuse or accept under certain circumstances. It is important to differentiate a living will from a durable power of attorney, which designates someone to make healthcare decisions on behalf of the individual when they are unable to do so, and advance directives, which encompass both a living will and a durable power of attorney for healthcare. The living will serves as a guide for healthcare professionals and family members to honor the individual's preferences for medical care.

Correct Answer: C

Rationale: The pharmacist is legally responsible in this situation because they are the healthcare professional authorized to dispense medications according to the physician's order. In this case, the physician ordered a dose higher than the maximum safe dose recommended based on the infant's current weight. While the nurse administers the medication, the pharmacist has the responsibility to ensure that the correct dose is dispensed and to alert the physician if there is a discrepancy in the order. If the pharmacist dispensed the incorrect dose without verifying with the physician, they would bear legal responsibility for any adverse effects resulting from the medication error.

Correct Answer: D

Rationale: In the scenario described, the patient is experiencing severe hypoxemia refractory to conventional oxygen therapy, indicating a need for advanced respiratory support. When a patient with ARDS fails to respond to conservative management, including mechanical ventilation strategies, prone positioning, and recruitment maneuvers, the next step may involve extracorporeal membrane oxygenation (ECMO). ECMO provides a way to bypass the lungs and oxygenate the blood directly, allowing for enhanced gas exchange and support for severely compromised respiratory function. Therefore, in this critical situation, prioritizing the recommendation for ECMO can offer the patient the best chance of improving oxygenation and survival.

Correct Answer: A

Rationale: The nurse should prioritize screening the patient for contraindications to MRI, such as metal implants or claustrophobia, to ensure procedural safety. Metallic objects can be hazardous in an MRI environment as they can be attracted to the magnet, potentially causing harm to the patient or staff. Claustrophobia can also be a significant issue for patients undergoing an MRI scan, and identifying this beforehand allows for appropriate measures to be taken to address the patient's anxiety or discomfort. Prioritizing this screening step helps ensure the safety and well-being of the patient during the MRI procedure.

Correct Answer: B

Rationale: When Nurse Sarah distributed a Patient satisfaction survey form to be filled by the consumer upon discharge in a hospital setting, it aligns with the quality standard of identifying Patient rights and welfare. Patient satisfaction surveys aim to gather feedback from patients about their experiences with the health care services provided. By distributing such surveys, the hospital is demonstrating its commitment to ensuring the rights and welfare of patients by seeking their feedback, understanding their concerns, and incorporating their suggestions for improvement. This initiative helps in enhancing the quality of care provided to patients and ultimately contributes to improving overall patient outcomes and satisfaction.

Correct Answer: D

Rationale: Using colored pictures can help make the presentation of the plan more visually engaging and easier to understand for the audience, in this case, the nurse's intended audience. Visual aids, such as colored pictures, can effectively convey complex information in a simplified and easy-to-digest manner. This approach can enhance comprehension and retention of the presented material, making the implementation of the plan more accessible and clear to the individuals involved.

Correct Answer: D

Rationale: The entry you expect to be written in Mrs. Carpio's progress report should include details related to monitoring her response to the Thiazide diuretics and ensuring her safety. Options A, B, and C all focus on these aspects by monitoring serum electrolytes, intake and output, and weight before drug administration, which are important considerations when a patient is on Thiazide diuretics. However, specifying the time of drug administration (8 o'clock in the evening) is not necessary in the progress report entry. The focus should be on the patient's response to the medication and the associated monitoring parameters. Time of administration is more relevant for nursing care plans or medication schedules.

Correct Answer: C

Rationale: When communicating with a patient from a different cultural background, the nurse should prioritize recognizing and respecting the patient's cultural beliefs and practices. This is essential in providing culturally competent care, fostering trust and rapport with the patient, and ultimately improving health outcomes. By acknowledging and understanding the cultural context of the patient, the nurse can adapt communication strategies, address the patient's needs effectively, and avoid misunderstandings or misinterpretations. Building a culturally sensitive approach can enhance the quality of care and strengthen the therapeutic relationship between the nurse and patient.