The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)

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Question 1 of 9

The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)

Correct Answer: A

Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.

Question 2 of 9

A nurse is teaching a health class about colorectalcancer. Which information should the nurse include in the teaching session? (Select all that apply.)

Correct Answer: A

Rationale: A. A risk factor is smoking: Smoking has been identified as a risk factor for colorectal cancer. It is important for the nurse to include this information during the teaching session to emphasize the importance of smoking cessation in reducing the risk of developing colorectal cancer.

Question 3 of 9

A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action?

Correct Answer: D

Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.

Question 4 of 9

To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select allthat apply.)

Correct Answer: A

Rationale: A. Allowing fasting on Yom Kippur for a Jewish patient demonstrates culturally sensitive care by respecting and accommodating the religious practices of the patient. Yom Kippur is an important day of fasting and repentance in the Jewish faith, and by allowing the patient to observe this practice, the nurse shows understanding and support.

Question 5 of 9

Which assessment by the nurNseU wRoSuIldN dGiffTerBen.tiCatOe Ma placenta previa from an abruptio placentae?

Correct Answer: A

Rationale: In the assessment of a patient with potential placenta previa or abruptio placentae, the nurse should pay close attention to the amount and characteristics of vaginal bleeding. Placenta previa typically presents with painless vaginal bleeding, which can be sudden and significant. Therefore, a saturated perineal pad within a short period of time (1 hour) is more indicative of placenta previa, as opposed to abruptio placentae which usually presents with painful vaginal bleeding and may not necessarily saturate a perineal pad quickly. Monitoring the amount of bleeding and keeping track of pad saturation over time can provide valuable information to differentiate between these two conditions.

Question 6 of 9

For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to

Correct Answer: A

Rationale: Rho(D) immune globulin (RhoGAM) needs to be administered within 72 hours postpartum to Rh-negative patients who have given birth to Rh-positive infants to prevent Rh sensitization. The patient delivered at 6:30 AM on January 10, so the RhoGAM should be administered prior to that time on January 13, which is 72 hours postpartum. Therefore, the correct choice is A. 6:30 AM on January 10.

Question 7 of 9

You are caring for a patient who has just been told that his illness is progressing and nothing more can be done for him. After the physician leaves, the patient asks you to stay with him for a while. The patient becomes tearful and tries several times to say something, but cannot get the words out. What would be an appropriate response for you to make at this time?

Correct Answer: C

Rationale: This response shows empathy and allows the patient to express their thoughts and feelings without feeling rushed or pressured. By asking the patient if there is anything they want to say, you are showing that you are there to listen and support them during this difficult time. It is important to give the patient the space and opportunity to communicate their emotions and concerns. Offering advice or making assumptions about the patient's feelings may not be as helpful as simply providing a listening ear.

Question 8 of 9

A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor?

Correct Answer: A

Rationale: Effective breast self-examination (BSE) relies significantly on women's knowledge of their own breasts. Understanding how their breasts normally look and feel allows women to detect any changes such as lumps, dimpling, or discharge, which may be early signs of breast abnormalities like cancer. By being familiar with their breasts' normal appearance and texture, women can promptly seek medical attention if they notice any unusual changes. This self-awareness and familiarity with their breasts are crucial in enabling women to perform BSE effectively and to detect any potential issues early on.

Question 9 of 9

An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurses most appropriate response?

Correct Answer: C

Rationale: Distorted lines on an Amsler grid can be an indication of changes in central vision, which is commonly seen in macular degeneration. Therefore, it is crucial for the nurse to arrange for the patient to visit his ophthalmologist promptly for further evaluation and management. The ophthalmologist will be able to determine the severity of the visual changes, provide appropriate treatment options, and closely monitor the progression of macular degeneration. This proactive approach ensures that the patient receives timely and specialized care for his condition. Options A, B, and D do not directly address the urgency of the situation and the need for specialized ophthalmologic evaluation in cases of macular degeneration.

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