While the nurse is taking yhe blood pressure, the patient suddenly stated."They are talking about me!". She was referring to other patients who were waiting for their consultation. Which of the following should be the APPROPRIATE nursing action?

Correct Answer: B

Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.

Correct Answer: D

Rationale: For a diagnostic pelvic ultrasound, one important preparation is to have the patient void or empty their bladder before the procedure. This allows for better visualization of the pelvic organs and structures during the ultrasound scan. A full bladder can obstruct the view and make it difficult to obtain accurate images. Therefore, it is essential for the patient to follow instructions to empty their bladder before the pelvic ultrasound to ensure the best results.

Correct Answer: A

Rationale: The nurse sharing Mr. Steve's medical records with a group of visiting members of a medical mission team violates his right to expect that all communications and records pertaining to his care should be treated as confidential. Patient confidentiality is a fundamental ethical principle in healthcare that protects a patient's privacy and sensitive information. Sharing medical records without the patient's consent breaches this confidentiality and can lead to legal and ethical consequences. It is important for healthcare providers to maintain the confidentiality of patient information to uphold trust between patients and healthcare professionals.

Correct Answer: D

Rationale: The BEST rationale for the conduct of the program is to deliver safe and quality nursing care to patients on intravenous therapy (IV). This directly ties the purpose of the program to the real-world outcome it seeks to achieve - providing optimal care for patients requiring intravenous therapy. Ensuring safe practice in the hospital (Option A) is important but it is not specific to the focus of the IV therapy program. Improving nursing practice in general (Option B) is a noble goal but the program should have a specific and targeted objective. Providing knowledge and skills to all nursing staff in IV Therapy (Option C) is essential, but the primary aim should be centered on improving patient care outcomes. Therefore, delivering safe and quality nursing care to patients on IV therapy aligns most closely with the core purpose of the program and should be the primary rationale.

Correct Answer: A

Rationale: After activating the emergency response system, the immediate priority in CPR is to begin chest compressions to support blood circulation. High-quality chest compressions are crucial in providing oxygen to vital organs, especially the brain, during cardiac arrest. Starting chest compressions promptly can improve the chances of survival for the person in need of CPR. Checking for breathing, performing abdominal thrusts, or assessing pulse should only be done after initiating chest compressions in the CPR sequence.

Correct Answer: A

Rationale: Having a tracheostomy means that a patient has an artificial opening in their neck to help them breathe. Therefore, any issues related to breathing, such as blockages in the tracheostomy tube or difficulty in clearing secretions, can pose a major problem for a patient with a tracheostomy. It is crucial to monitor the patient's respiratory status closely and intervene promptly if any breathing difficulties arise to prevent potential respiratory distress or complications.

Correct Answer: B

Rationale: The past medical history section typically includes information about a person's medical background before the current point in time. This would involve details such as prenatal history, birth history, childhood illnesses, surgeries, and medical conditions that have occurred in the past. "Current history" would be more appropriate for the present medical status and ongoing health issues, hence it does not belong in the past medical history section.

Correct Answer: C

Rationale: Delegation by succession is the act of assigning a specific task or responsibility to someone temporarily while the usual person in charge is absent or unavailable. In this scenario, the unit manager is delegating her responsibilities to her assistant unit manager while she is on leave, indicating a temporary transfer of duties. This allows for a smooth continuity of operations within the unit during the manager's absence.

Correct Answer: A

Rationale: The patient's presentation of fatigue, weakness, jaundice, elevated indirect bilirubin levels, reticulocytosis, and positive Coombs test is consistent with hemolytic anemia. Among the options provided, hereditary spherocytosis is the most likely condition to cause these findings.