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","B","D","E"]
Explanation
Choice A reason: This is a correct choice because autonomy is a key element of decentralized decision making. Autonomy refers to the ability and right of individuals or groups to make their own decisions without interference from others. Decentralized decision making empowers the employees to exercise their autonomy and use their own judgment and expertise to solve problems and improve performance².
Choice B reason: This is a correct choice because authority is a key element of decentralized decision making. Authority refers to the power and legitimacy to make decisions and take actions. Decentralized decision making delegates the authority from the top management to the lower levels of the organization, allowing them to make decisions that affect their work and outcomes².
Choice C reason: This is an incorrect choice because prioritization is not a key element of decentralized decision making. Prioritization refers to the process of ranking tasks or goals according to their importance and urgency. Decentralized decision making does not necessarily involve prioritization, as different individuals or groups may have different criteria and preferences for setting their priorities².
Choice D reason: This is a correct choice because responsibility is a key element of decentralized decision making. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. Decentralized decision making assigns the responsibility to the individuals or groups who make the decisions and hold them accountable for their actions and outcomes².
Choice E reason: This is a correct choice because accountability is a key element of decentralized decision making. Accountability refers to the expectation and requirement to report and explain the decisions and actions taken and the results achieved. Decentralized decision making ensures that the individuals or groups who make the decisions are accountable for their performance and quality, and that they receive feedback and recognition for their work².
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because presence of pedal pulses and intact sensation is the most important bath time assessment of the diabetic patient. Pedal pulses are the pulses that can be felt on the top or side of the foot, and they indicate the blood flow to the lower extremities. Intact sensation is the ability to feel touch, pain, temperature, and vibration on the skin, and it indicates the nerve function of the lower extremities. Diabetic patients are at risk of developing peripheral vascular disease and peripheral neuropathy, which can impair the blood flow and nerve function of the lower extremities, and lead to ulcers, infections, or amputations. The nurse should assess the pedal pulses and intact sensation of the diabetic patient regularly, especially before and after bathing, to monitor for any signs of complications or deterioration.
Choice B reason: This is an incorrect choice because presence of fingernail clubbing is not the most important bath time assessment of the diabetic patient. Fingernail clubbing is a condition where the nails become curved and enlarged, and the nail bed becomes soft and spongy. It is a sign of chronic hypoxia or low oxygen levels in the blood, and it can be associated with various diseases such as lung cancer, cystic fibrosis, or congenital heart defects. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.
Choice C reason: This is an incorrect choice because presence of abdominal rebound tenderness is not the most important bath time assessment of the diabetic patient. Abdominal rebound tenderness is a sign of peritoneal inflammation, which is the inflammation of the membrane that lines the abdominal cavity and organs. It is elicited by pressing and releasing the abdomen quickly, and it causes pain when the pressure is released. It can be caused by various conditions such as appendicitis, diverticulitis, or peritonitis. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.
Choice D reason: This is an incorrect choice because presence of any petechiae or bruises is not the most important bath time assessment of the diabetic patient. Petechiae are small, red, or purple spots on the skin that are caused by bleeding under the skin. Bruises are larger, blue, or purple areas on the skin that are caused by bleeding under the skin. They can be caused by various factors such as trauma, infection, medication, or blood disorders. However, they are not a common or specific complication of diabetes, and they do not pose an immediate risk of harm or injury to the diabetic patient.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.