When preparing the patient for suctioning, what is the FIRST step?

Correct Answer: D

Rationale: Before any procedure, it is crucial to ensure that you have the proper authorization and guidelines in place. By checking the physician's order and the patient care plan, you confirm that suctioning is indeed needed and that you follow the specific instructions for that patient. This step helps ensure patient safety and effective care delivery. Once you have verified this information, you can proceed with gathering equipment, performing hand hygiene, and assessing the patient's condition as necessary.

Correct Answer: D

Rationale: The symptoms described by the patient indicate a potential transfusion reaction, such as a hemolytic reaction or allergic reaction. The immediate action the nurse should take in such a situation is to stop the infusion of the packed red blood cells. This will help prevent further complications and ensure the safety of the patient. After stopping the infusion, the nurse should assess the patient's condition, monitor vital signs, and inform the healthcare team, including the physician, regarding the situation. Once the patient is stable, further investigations can be conducted to determine the cause of the reaction.

Correct Answer: A

Rationale: A nursing assistant can be delegated the task of changing wound dressings because it is considered a basic nursing care activity that does not require specialized training or knowledge. Nursing assistants are trained to perform tasks related to personal care, hygiene, and basic wound care under the supervision of a registered nurse. Changing wound dressings is a routine nursing task that can be safely delegated to a nursing assistant, allowing the nurse to focus on other aspects of patient care that require specialized nursing skills and knowledge.

Correct Answer: B

Rationale: It is important for the nurse to have a direct and easily accessible means of communication with the patient who is expected to be in and out of the hospital due to their chronic illness like leukemia. By asking for the patient's phone number, the nurse can quickly reach out to them for updates, clarification, or any urgent matters that may arise. This direct communication line helps in ensuring continuity of care and addressing the patient's needs promptly. This approach is more practical and efficient compared to options such as asking the patient to call the hospital number listed in the yellow pages or relying on chart information which may not always be up to date. Writing down the number and giving it to the ward clerk may cause unnecessary delays in communication.

Correct Answer: B

Rationale: Acetaminophen (Tylenol) is given pre-operatively to decrease intra-operative anesthetic requirements and post-operative pain. It is a common analgesic that can help reduce the amount of intra-operative anesthesia needed and provide some pain relief during the surgery. Unlike drugs like Celebrex, Ibuprofen, and Demerol, Acetaminophen does not have anti-inflammatory properties, but it is effective in managing pain and can contribute to overall pain control before, during, and after surgery. This makes it a preferred choice for pre-operative medication in order to decrease the need for higher doses of anesthetics and reduce post-operative pain levels.