Transcription of doctor's order is a nurse's responsibility to put the order into action. Which of the following principles of medication safety is NOT considered to belong to transcription error?

Correct Answer: D

Rationale: Transcription errors are typically associated with issues such as illegible handwriting, misinterpretation of directions, and the use of unapproved abbreviations. However, the wrong route of medication administration is not specifically related to transcription errors but rather falls under the category of medication administration errors. Administering medication via the wrong route can lead to serious consequences for the patient and is a separate issue from the act of transcribing doctor's orders.

Correct Answer: B

Rationale: In this scenario, the nurse is asking the patient to elaborate on their feelings and thoughts related to the upcoming surgery. By asking, "What do you fear MOST about your surgery tomorrow?" the nurse is seeking clarification to better understand the patient's concerns and enable effective communication. Seeking clarification involves asking open-ended questions that encourage the patient to express themselves more fully, allowing the healthcare provider to address their specific worries or needs more effectively.

Correct Answer: A

Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.

Correct Answer: A

Rationale: The presentation of well-demarcated, hypopigmented macules with fine scaling on the trunk and proximal extremities is classic for tinea versicolor. Tinea versicolor is a common superficial fungal infection caused by Malassezia spp., which leads to hypo- or hyperpigmented patches on the skin. The condition often occurs in individuals with increased sebum production due to factors such as hot and humid climates, sweating, and oily skin. History of sun exposure and outdoor activities is also commonly reported by patients with tinea versicolor. Treatment usually involves antifungal medications applied topically or taken orally to eliminate the fungus. Differentiating tinea versicolor from other skin conditions, such as vitiligo, pityriasis rosea, or seborrheic keratosis, is important for appropriate management.

Correct Answer: D

Rationale: The most common symptom of scabies that the family would report to Nurse Emma is itchiness. Scabies is a contagious skin condition caused by the Sarcoptes scabiei mite, which burrows into the skin and lays eggs, leading to intense itching, especially at night. The itching is a result of the body's allergic reaction to the mites and their waste products. While rashes, scaling, and swelling can also occur with scabies, the hallmark and most bothersome symptom experienced by individuals with scabies is the intense itchiness, making it the most common symptom reported by affected individuals or their families during the history-taking process.

Correct Answer: B

Rationale: The clinical scenario described is consistent with a diagnosis of anterior epistaxis due to a prominent vascular lesion located in Little's area, which is an important site for nosebleeds. Silver nitrate cautery is the most appropriate intervention for managing this condition. Silver nitrate cautery is a commonly used method to chemically cauterize and eliminate the friable blood vessels responsible for recurrent epistaxis. It is a cost-effective and minimally invasive technique that can be easily performed in an outpatient setting. Nasal packing with anterior nasal tampons might be considered in cases of severe or refractory epistaxis, but in this scenario, where the source of bleeding is localized and identifiable, silver nitrate cautery is the treatment of choice. Endoscopic cauterization of the sphenopalatine artery and surgical excision of a nasal polyp are unnecessary and overly invasive for the described scenario.

Correct Answer: B

Rationale: In this scenario, the physician-specialist assessed the patient and determined that an immediate sonogram is needed for the medical condition. An intervention is a specific action taken in response to a medical need or condition. Ordering an immediate sonogram falls under the category of an intervention because it involves a timely and targeted diagnostic procedure to address the medical situation identified by the physician. The other options (A. Operation Room, C. Laboratory, D. CT scan) do not accurately represent the specific action of ordering a sonogram in response to the medical condition assessed by the physician.

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.

Correct Answer: A

Rationale: In this critical situation, the safety of the wife is of utmost importance. Whenever a healthcare provider becomes aware of a direct threat to someone's safety, especially related to potential harm or violence, it is their ethical and legal responsibility to report this information to the appropriate authorities promptly. In this case, the nurse should alert the proper authorities, such as law enforcement or a mental health crisis team, to ensure that immediate steps are taken to protect the wife from harm. Confidentiality should be breached in situations where there is a clear threat to an individual's safety. Keeping the information confidential in this scenario could result in serious harm or even loss of life. The nurse must act quickly to protect the potential victim.