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: A

Rationale: In this scenario, the nurse's failure to promptly prepare the patient for transfer to a tertiary hospital resulted in the patient's death. This situation falls under the category of malpractice, which refers to professional negligence or failure to provide a standard level of care that results in harm to a patient. The nurse had a duty to ensure the patient's timely transfer and by delaying the necessary actions, the nurse failed to uphold this duty, leading to a tragic outcome. Murder, assault, and battery are criminal offenses that do not fit the circumstances described in the scenario.

Correct Answer: A

Rationale: Prior to a gastric lavage procedure, it is essential for the nurse to ensure the correct size of the nasogastric tube is selected. The appropriate size of the tube will allow for effective removal of the ingested poisonous substance during the procedure. Proper sizing also helps in preventing complications such as injury to the gastrointestinal tract or inadequate removal of the substance. This step is crucial for the safe and successful completion of gastric lavage. Reminding parents to be careful, obtaining informed consent immediately, or accusing them of negligence are not immediate responsibilities of the nurse in this context.

Correct Answer: B

Rationale: When a medication is unavailable and therefore not given to the patient, it is important to document this in the Nurses Notes along with an explanation. Leaving it blank (Option A) may lead to confusion or errors as the reason for not administering the medication would not be clear. Using an asterisk or mark as per hospital protocol (Option C) may not provide enough information about why the medication was missed. Writing the letter (Option D) without any explanation would not suffice in terms of documentation and accountability. Therefore, signing and making an explanation in the Nurses Notes (Option B) is the correct way to chart when a medication is unavailable. This ensures proper documentation of the situation and helps in maintaining the continuity of care for the patient.

Correct Answer: A

Rationale: The first priority for a nurse caring for a patient experiencing a seizure is safety. Ensuring the safety of the patient is crucial to prevent injury during the seizure episode. This includes clearing the area around the patient of any harmful objects, preventing the patient from falling or hitting their head, placing them in a safe position to prevent aspiration if they vomit, and staying with the patient until the seizure ends. Once the patient is safe, the nurse can then focus on other aspects of care such as assessing airway, providing emotional support, and monitoring for complications.