The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?

Explain the importance of maintaining morning hygiene practices.

Tell the patient that daily morning baths are the "normal" routine.

Cancel hygiene for the day and attempt again in the morning.

Defer the bath until evening and pass on the information to the next shift.

Answer and Explanation

The Correct Answer is D

A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.

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Correct Answer is D

Explanation

A. The superior vena cava is responsible for returning deoxygenated blood from the upper body to the heart and is not directly involved in myocardial ischemia.
B. The carotid artery supplies blood to the brain and is not the primary focus in the context of myocardial infarction.
C. The pulmonary artery carries deoxygenated blood from the heart to the lungs and is not involved in coronary circulation.
D. The coronary arteries supply blood to the heart muscle itself. Ischemia during a myocardial infarction occurs when these arteries are blocked or narrowed, leading to a lack of blood flow and oxygen to the heart tissue.

A. Give the injection and hold pressure over the site for 3 minutes. B. Administer the injection at a slower rate. C. Withdraw the needle and prepare the injection again. D. Pull the needle back slightly and inject the medication.

Correct Answer is C

Explanation

A. Continuing with the injection after seeing blood return increases the risk of injecting into a blood vessel, which is not safe for IM injections.
B. Administering at a slower rate does not address the issue of possible intravascular injection.
C. If blood is aspirated, the correct procedure is to withdraw the needle, dispose of the medication, and prepare a new dose to prevent intravascular administration, as IM injections are meant to be given into muscle tissue, not into a vein.
D. Pulling the needle back slightly is not recommended because it does not ensure that the needle is completely out of the blood vessel.

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The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has experienced a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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