What are the priority actions of the nurse who enters the patient’s room to begin teaching the patient about wound care management and notes that the patient is nauseated due to medication side effects? (Select all that apply).
Check the patient’s order list to determine if antiemetic medication has been prescribed for the patient.
Begin teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting.
Provide measures to relieve the patient’s nausea and return to teach about wound care when the patient is feeling better.
Apply a cold cloth to the patient's forehead and maintain a quiet odor-free environment for the patient.
Document in the patient’s chart that teaching about wound care management was not done because the patient refused to learn.
Correct Answer : A,C
Choice A reason: This is a correct choice because checking the patient’s order list to determine if antiemetic medication has been prescribed for the patient is a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is important to manage the patient's nausea and prevent vomiting, which can lead to dehydration, electrolyte imbalance, and aspiration. The nurse should follow the physician's orders and administer the antiemetic medication as indicated.
Choice B reason: This is an incorrect choice because beginning teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting, is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is not appropriate to perform when the patient is feeling sick and uncomfortable, as it may impair the patient's learning ability and motivation. The nurse should postpone the teaching until the patient's nausea is resolved and the patient is ready to learn.
Choice C reason: This is a correct choice because providing measures to relieve the patient’s nausea and returning to teach about wound care when the patient is feeling better is a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is essential to address the patient's immediate need and comfort, and to ensure that the patient receives the necessary education about wound care management at a suitable time. The nurse should provide measures such as offering clear liquids, crackers, or ginger, positioning the patient in a semi-Fowler's position, and providing a basin or emesis bag if needed.
Choice D reason: This is an incorrect choice because applying a cold cloth to the patient's forehead and maintaining a quiet odor-free environment for the patient is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is a supportive measure that may help to soothe the patient's nausea, but it is not sufficient to treat the underlying cause or prevent further complications. The nurse should also check the patient's order list and administer the antiemetic medication if prescribed.
Choice E reason: This is an incorrect choice because documenting in the patient’s chart that teaching about wound care management was not done because the patient refused to learn is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is a false and inaccurate documentation that does not reflect the patient's condition or the nurse's actions. The nurse should document the patient's nausea, the interventions provided, and the plan to resume the teaching when the patient is feeling better.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct. Teaching the patient to wear low-heeled, comfortable, supportive footwear at all times is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet. This can prevent foot injuries, ulcers, and infections that can lead to amputation.
Choice B reason: This is incorrect. Encouraging the patient to participate in tai chi exercises to promote balance is a beneficial intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Tai chi can improve muscle strength, coordination, and flexibility, but it does not protect the feet from injury.
Choice C reason: This is incorrect. Evaluating the patient's blood pressure for orthostatic hypotension is an important intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Orthostatic hypotension is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting. It can be caused by autonomic neuropathy, which affects the nerves that control blood pressure and heart rate.
Choice D reason: This is incorrect. Instructing the patient to wear a medical alert bracelet that identifies risk for falls is a helpful intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. A medical alert bracelet can alert emergency personnel of the patient's condition and medications, but it does not prevent falls or foot injuries.
Correct Answer is ["B","D"]
Explanation
Choice A reason: This is incorrect. Tramadol is not a nonsteroidal anti-inflammatory medication. Tramadol is an opioid analgesic medication that works by binding to opioid receptors in the brain and spinal cord. It can relieve moderate to severe pain, but it does not have any anti-inflammatory effect.
Choice B reason: This is correct. Aspirin is a nonsteroidal anti-inflammatory medication. Aspirin is a salicylate medication that works by inhibiting the enzyme cyclooxygenase, which is involved in the synthesis of prostaglandins. Prostaglandins are chemical messengers that mediate inflammation, pain, and fever. Aspirin can reduce inflammation, pain, and fever, as well as prevent blood clots and protect the heart.
Choice C reason: This is incorrect. Acetaminophen is not a nonsteroidal anti-inflammatory medication. Acetaminophen is a para-aminophenol medication that works by inhibiting the enzyme cyclooxygenase in the central nervous system, but not in the peripheral tissues. It can reduce pain and fever, but it does not have any anti-inflammatory effect.
Choice D reason: This is correct. Ibuprofen is a nonsteroidal anti-inflammatory medication. Ibuprofen is a propionic acid medication that works by inhibiting the enzyme cyclooxygenase, which is involved in the synthesis of prostaglandins. Prostaglandins are chemical messengers that mediate inflammation, pain, and fever. Ibuprofen can reduce inflammation, pain, and fever, as well as treat arthritis and menstrual cramps.
Choice E reason: This is incorrect. Codeine is not a nonsteroidal anti-inflammatory medication. Codeine is an opioid analgesic medication that works by binding to opioid receptors in the brain and spinal cord. It can relieve mild to moderate pain, but it does not have any anti-inflammatory effect.
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