A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

“You will not be able to eat breakfast until after you are washed.”.

“Please tell me what is worrying you at this time.”.

“I am going to wash you now and then you will take your medications.”.

“Why are you crying again? We haven’t touched you yet.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.

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Correct Answer is D

Explanation

Choice A rationale
The use of a Passy Muir speaking valve can be important for communication, but it is not the highest priority for discharge teaching.
Choice B rationale
Having the phone number of the healthcare provider to report complications is important, but it is not the highest priority. The patient needs to know how to prevent and recognize complications first.
Choice C rationale
While having emergency personal identification that the patient is unable to speak is important, it is not the highest priority. The patient’s immediate post-operative needs should be addressed first.
Choice D rationale
The ability to perform tracheostomy care is the highest priority for discharge teaching. This is a new and critical skill that the patient must learn to prevent complications, maintain the airway, and manage their own care at home.

A. Auscultate lungs for the presence of breath sounds. B. Determine that the pulse oximetry is greater than 95%. C. Assess baseline level of consciousness. D. Assess for the presence of circumoral cyanosis.

Correct Answer is A

Explanation

Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.

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A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to discharge a patient who is post-operative following a laryngectomy. The nurse should recognize which of the following discharge teaching as the highest priority?

Correct Answer is D

Explanation

A nurse is caring for a patient immediately following endotracheal intubation. Which of the following actions should the nurse prioritize to assess the patient for complications?

Correct Answer is A

Explanation

A nurse is caring for a patient at risk for atelectasis. Which independent nursing measure should the nurse prioritize to prevent the development of atelectasis?

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