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 B
Explanation
Choice A reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Choice B reason: This is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is relevant, open-ended, and comprehensive. The nurse should ask questions that are related to the patient's health status, needs, or goals, and that elicit more information from the patient. This question allows the patient to describe the onset, duration, and frequency of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.
Choice C reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Choice D reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Correct Answer is A
Explanation
Choice A reason: This is correct. Unilateral neglect is a condition where the patient fails to attend to or respond to stimuli on the opposite side of the brain lesion. It can affect the patient's perception, attention, memory, and motor function. It can also impair the patient's safety, self-care, and quality of life. The patient may not recognize the existence of the paralyzed limbs, ignore them, or deny their ownership.
Choice B reason: This is incorrect. Ineffective denial is a condition where the patient consciously or unconsciously refuses to acknowledge the reality of a situation that is too threatening or overwhelming. It can interfere with the patient's coping and adaptation. The patient may reject the diagnosis, prognosis, or treatment of the condition. However, this is not the case for the patient with unilateral neglect, who is not aware of the paralysis, rather than refusing to accept it.
Choice C reason: This is incorrect. Deficient knowledge is a condition where the patient lacks or misinterprets information about a topic related to health or illness. It can affect the patient's decision-making, compliance, and outcomes. The patient may have inaccurate or incomplete understanding of the causes, consequences, or management of the condition. However, this is not the main problem for the patient with unilateral neglect, who is not able to process or attend to the information, rather than lacking it.
Choice D reason: This is incorrect. Noncompliance is a condition where the patient does not or is unable to follow the prescribed or agreed-upon plan of care. It can result from various factors, such as lack of motivation, resources, support, or understanding. The patient may not adhere to the recommendations, instructions, or goals of the treatment. However, this is not the primary issue for the patient with unilateral neglect, who is not capable of performing the tasks, rather than unwilling to do so.
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