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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice because providing a warm cup of hot chocolate may make it more difficult for the patient to fall asleep. Hot chocolate contains caffeine and sugar, which are stimulants that can interfere with the sleep cycle and cause insomnia. The nurse should avoid giving the patient any beverages or foods that contain caffeine or sugar before bedtime.

Choice B reason: This is an incorrect choice because giving the patient a gentle backrub may make it easier for the patient to fall asleep. A backrub is a relaxation technique that can reduce muscle tension, pain, and anxiety, and promote comfort and sleep. The nurse should offer the patient a backrub or other soothing interventions before bedtime.

Choice C reason: This is an incorrect choice because encouraging the patient to use the bathroom may make it easier for the patient to fall asleep. Using the bathroom before bed can prevent nocturia, which is the need to urinate at night, and allow the patient to have uninterrupted sleep. The nurse should assist the patient to use the bathroom or provide a urinal or bedpan if needed.

Choice D reason: This is an incorrect choice because giving the patient an extra blanket when cold may make it easier for the patient to fall asleep. Maintaining a comfortable temperature is important for sleep quality and quantity. The nurse should adjust the room temperature and provide extra blankets or fans as requested by the patient.

A. Calculating the patient’s fluid intake and output at the end of every shift. B. Assessing the patient’s abdomen for distention, bowel sounds, and passage of flatus. C. Administering a mild stool softener daily to prevent constipation. D. Encouraging fluid and fiber intake to prevent constipation from pain medications. E. Reinserting the patient's urinary catheter for retention of greater than 500 mL of urine.

Correct Answer is ["C"]

Explanation

Choice A reason: This is an incorrect choice because calculating the patient’s fluid intake and output at the end of every shift is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can monitor the patient’s fluid balance and document the results.

Choice B reason: This is an incorrect choice because assessing the patient’s abdomen for distention, bowel sounds, and passage of flatus is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can perform a physical examination of the patient’s abdomen and document the findings.

Choice C reason: This is a correct choice because administering a mild stool softener daily to prevent constipation is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot give any medication to the patient without a prescription.

Choice D reason: This is an incorrect choice because encouraging fluid and fiber intake to prevent constipation from pain medications is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can educate the patient about the importance of hydration and nutrition and document the teaching.

Choice E reason: This is a correct choice because reinserting the patient's urinary catheter for retention of greater than 500 mL of urine is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot insert or remove any invasive device from the patient without a prescription.

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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).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which bedtime action by the nurse may make it more difficult for the patient to fall asleep?

Correct Answer is A

Explanation

Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient? (Select all that apply).

Correct Answer is ["C"]

Explanation

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